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Ren L, Jäger C, Schorn S, Pergolini I, Göß R, Safak O, Kießler M, Martignoni ME, Novotny AR, Friess H, Ceyhan GO, Demir IE. Arterial Resection for Pancreatic Cancer: Feasibility and Current Standing in a High-Volume Center. ANNALS OF SURGERY OPEN 2023; 4:e302. [PMID: 37746627 PMCID: PMC10513225 DOI: 10.1097/as9.0000000000000302] [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: 01/03/2023] [Accepted: 05/31/2023] [Indexed: 09/26/2023] Open
Abstract
Background Arterial resection (AR) during pancreatectomy for curative R0 resection of pancreatic ductal adenocarcinoma (PDAC) remains a controversial procedure with high morbidity. Objective To investigate the feasibility and oncological outcomes of pancreatectomy combined with AR at a high-volume center for pancreatic surgery. Methods We retrospectively analyzed our experience in PDAC patients, who underwent pancreatic resection with AR and/or venous resection (VR) between 2007 and 2021. Results In total 259 PDAC patients with borderline resectable (n = 138) or locally advanced (n = 121) PDAC underwent vascular resection during tumor resection. From these, 23 patients had AR (n = 4 due to intraoperative injury, n = 19 due to suspected arterial infiltration). However, 12 out of 23 patients (52.2%) underwent simultaneous VR including 1 case with intraoperative arterial injury. In comparison, 11 patients (47.8%) underwent AR only including 3 intraoperative arterial injury patients. Although the operation time and bleeding rate of patients with AR were respectively longer and higher than in VR, no significant difference was detected in postoperative complications between VR and AR (P = 0.11). The final histopathological findings of PDAC patients were similar, including M stage, regional lymph node metastases, and R0 margin resection. The mortality of the entire cohort was 6.2% (16/259), with a tendency to increase mortality in the AR cohort, yet without statistical significance (VR: 5% vs AR: 21.1%; P = 0.05). Although 19 (82.6%) patients had PDAC in the final histopathology, only 6 were confirmed to have infiltrated arteria. The microscopic distribution of PDAC in these infiltrated arterial walls on hematoxylin-eosin staining was classified into 3 patterns. Strikingly, the perivascular nerves frequently exhibited perineural invasion. Conclusions AR can be performed in high-volume centers for pancreatic surgery with an acceptable morbidity, which is comparable to that of VR. However, the likelihood of arterial infiltration seems to be rather overestimated, and as such, AR might be avoidable or replaced by less invasive techniques such as divestment during PDAC surgery.
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Affiliation(s)
- Lei Ren
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- Department of General Surgery (Gastrointestinal Surgery), The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Carsten Jäger
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Stephan Schorn
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Ilaria Pergolini
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Rüdiger Göß
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Okan Safak
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Maximilian Kießler
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Marc E. Martignoni
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Alexander R. Novotny
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Helmut Friess
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Güralp O. Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ihsan Ekin Demir
- From the Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
- Else Kröner Clinician Scientist Professor for Translational Pancreatic Surgery, Munich, Germany
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Wang D, Cui SP, Chen Q, Ren ZY, Lyu SC, Zhao X, Lang R. The coagulation-related genes for prognosis and tumor microenvironment in pancreatic ductal adenocarcinoma. BMC Cancer 2023; 23:601. [PMID: 37386391 DOI: 10.1186/s12885-023-11032-9] [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: 01/25/2023] [Accepted: 05/31/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is a malignancy characterized by challenging early diagnosis and poor prognosis. It is believed that coagulation has an impact on the tumor microenvironment of PDAC. The aim of this study is to further distinguish coagulation-related genes and investigate immune infiltration in PDAC. METHODS We gathered two subtypes of coagulation-related genes from the KEGG database, and acquired transcriptome sequencing data and clinical information on PDAC from The Cancer Genome Atlas (TCGA) database. Using an unsupervised clustering method, we categorized patients into distinct clusters. We investigated the mutation frequency to explore genomic features and performed enrichment analysis, utilizing Gene Ontology (GO) and Kyoto Encyclopedia of Genes (KEGG) to explore pathways. CIBERSORT was used to analyze the relationship between tumor immune infiltration and the two clusters. A prognostic model was created for risk stratification, and a nomogram was established to assist in determining the risk score. The response to immunotherapy was assessed using the IMvigor210 cohort. Finally, PDAC patients were recruited, and experimental samples were collected to validate the infiltration of neutrophils using immunohistochemistry. In addition, and identify the ITGA2 expression and function were identified by analyzing single cell sequencing data. RESULTS Two coagulation-related clusters were established based on the coagulation pathways present in PDAC patients. Functional enrichment analysis revealed different pathways in the two clusters. Approximately 49.4% of PDAC patients experienced DNA mutation in coagulation-related genes. Patients in the two clusters displayed significant differences in terms of immune cell infiltration, immune checkpoint, tumor microenvironment and TMB. We developed a 4-gene prognostic stratified model through LASSO analysis. Based on the risk score, the nomogram can accurately predict the prognosis in PDAC patients. We identified ITGA2 as a hub gene, which linked to poor overall survival (OS) and short disease-free survival (DFS). Single-cell sequencing analysis demonstrated that ITGA2 was expressed by ductal cells in PDAC. CONCLUSIONS Our study demonstrated the correlation between coagulation-related genes and the tumor immune microenvironment. The stratified model can predict the prognosis and calculate the benefits of drug therapy, thus providing the recommendations for clinical personalized treatment.
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Affiliation(s)
- Di Wang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Song-Ping Cui
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Qing Chen
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Zhang-Yong Ren
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Shao-Cheng Lyu
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Xin Zhao
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Ren Lang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People's Republic of China.
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Sood D, Kuchta K, Paterakos P, Schwarz JL, Rojas A, Choi SH, Vining CC, Talamonti MS, Hogg ME. Extended postoperative thromboprophylaxis after pancreatic resection for pancreatic cancer is associated with decreased risk of venous thromboembolism in the minimally invasive approach. J Surg Oncol 2023; 127:413-425. [PMID: 36367398 DOI: 10.1002/jso.27135] [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: 07/04/2022] [Revised: 10/17/2022] [Accepted: 10/23/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is associated with increased venous thromboembolism (VTE). We sought to compare rates of bleeding complications and VTE in patients receiving extended postoperative thromboprophylaxis (EPT) to those who did not, and identify risk factors for VTE after pancreatectomy for PDAC. METHODS This is a retrospective review of pancreatectomies for PDAC. EPT was defined as 28 days of low molecular weight heparin. Multivariable analysis (MVA) was performed to identify independent risk factors of VTE. RESULTS Of 269 patients included, 142 (52.8%) received EPT. Of those who received EPT, 7 (4.9%) suffered bleeding complications, compared to 6 (4.7%) of those who did not (p = 0.938). There was no significant difference in VTE rate at 90 days (2.8% vs. 2.4%, p = 0.728) or at 1 year (6.3% vs. 7.9%, p = 0.624). On MVA, risk factors for VTE included worse performance status, lower preoperative hematocrit, R1/R2 resection, and minimally invasive (MIS) approach. Among those who received EPT, there was no difference in VTE rate between MIS and open approach. CONCLUSIONS EPT was not associated with a difference in VTE risk or bleeding complications. MIS approach was associated with a higher risk of VTE; however, this was significantly lower among those who received EPT.
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Affiliation(s)
- Divya Sood
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Pierce Paterakos
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Jason L Schwarz
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Aram Rojas
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Sung H Choi
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Charles C Vining
- Department of Surgery, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
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García Adrián S, González AR, de Castro EM, Olmos VP, Morán LO, Del Prado PM, Fernández MS, Burón JDC, Escobar IG, Galán JM, Pérez AIF, Neria F, Lavin DC, Hernández BLDSV, Jiménez-Fonseca P, Muñoz Martín AJ. Incidence, risk factors, and evolution of venous thromboembolic events in patients diagnosed with pancreatic carcinoma and treated with chemotherapy on an outpatient basis. Eur J Intern Med 2022; 105:30-37. [PMID: 35931614 DOI: 10.1016/j.ejim.2022.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreatic carcinoma is one of the tumors associated with a higher risk for thromboembolic events, with incidence rates ranging from 5% to 41% in previous retrospective series. PATIENTS AND METHODS We conducted a retrospective study in eleven Spanish hospitals that included 666 patients diagnosed with pancreatic carcinoma (any stage) between 2008 and 2011 and treated with chemotherapy. The main objective was to evaluate the incidence of venous thromboembolic events (VTE) in this population, as well as potential risk factors for thrombosis. The impact of VTE on mortality was also assessed. RESULTS With a median follow-up of 9.3 months, the incidence of VTE was 22.1%; 52% were diagnosed incidentally. Our study was unable to confirm the ability of the Khorana score to discriminate between patients in the intermediate or high risk category for thrombosis. The presence of VTE proved to be an independent prognostic factor associated with increased risk of death (HR 2.39, 95% CI 1.96-2.92). Symptomatic events correlated with higher mortality than asymptomatic events (HR 1.72; 95% CI, 1.21-2.45; p = 0.002), but incidental VTE, including visceral vein thrombosis (VVT), negatively affected survival compared to patients without VTE. Subjects who developed VTE within the first 3 months of diagnosis of pancreatic carcinoma had lower survival rates than those with VTE after 3 months (HR 1.92, 95% CI 1.30-2.84; p<0.001). CONCLUSIONS Pancreatic carcinoma is associated with a high incidence of VTE, which, when present, correlates with worse survival, even when thrombosis is incidental. Early onset VTE has a particularly negative impact.
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Affiliation(s)
- Silvia García Adrián
- Medical Oncology Department, Hospital Universtario de Móstoles, C/ Dr. Luis Montes S/N, Madrid 28935, Spain; Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain.
| | - Adán Rodríguez González
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Eva Martínez de Castro
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Vanessa Pachón Olmos
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Laura Ortega Morán
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Purificación Martínez Del Prado
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario de Basurto, Bilbao, Spain
| | - Mercedes Salgado Fernández
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Complejo Universitario de Orense, Orense, Spain
| | - José David Cumplido Burón
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital de Torrevieja, Torrevieja, Spain
| | - Ignacio García Escobar
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Joaquina Martínez Galán
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Ana Isabel Ferrer Pérez
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Fernando Neria
- Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Diego Cacho Lavin
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Borja López de San Vicente Hernández
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario de Basurto, Bilbao, Spain
| | - Paula Jiménez-Fonseca
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Andrés J Muñoz Martín
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
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Interventional Management of Portal Hypertension in Cancer Patients. Curr Oncol Rep 2022; 24:1461-1475. [PMID: 35953600 DOI: 10.1007/s11912-022-01319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of the classifications and clinical hallmarks of common cancer-related conditions that contribute to the high incidence of portal hypertension in this population and provide an update on currently available interventional radiology therapeutic approaches. RECENT FINDINGS In the last few decades, there have been significant advancements in understanding the pathophysiology of portal hypertension. This knowledge has led to the development of safer and more effective minimally invasive approaches. The main objective is to provide alternatives to prevent life-threatening complications from clinically significant portal hypertension and to allow the continuation of cancer treatment interventions that would otherwise be stopped. Clinicians involved in cancer care should be aware of risk factors, associated complications, and management of portal hypertension in cancer patients. Interventional radiology offers minimally invasive alternatives that play a central role in improving clinical outcomes and survival of these patients, allowing the continuation of cancer treatments.
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6
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Chen Z, Wei X, Dong S, Han F, He R, Zhou W. Challenges and Opportunities Associated With Platelets in Pancreatic Cancer. Front Oncol 2022; 12:850485. [PMID: 35494001 PMCID: PMC9039220 DOI: 10.3389/fonc.2022.850485] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/15/2022] [Indexed: 01/02/2023] Open
Abstract
Pancreatic cancer is one of the most common malignant tumors in the digestive system with a poor prognosis. Accordingly, better understanding of the molecular mechanisms and innovative therapies are warranted to improve the prognosis of this patient population. In addition to playing a crucial role in coagulation, platelets reportedly contribute to the growth, invasion and metastasis of various tumors, including pancreatic cancer. This narrative review brings together currently available evidence on the impact of platelets on pancreatic cancer, including the platelet-related molecular mechanisms of cancer promotion, pancreatic cancer fibrosis, immune evasion, drug resistance mechanisms, thrombosis, targeted platelet therapy, combined radiotherapy and chemotherapy treatment, platelet combined with nanotechnology treatment and potential applications of pancreatic cancer organoids. A refined understanding of the role of platelets in pancreatic cancer provides the foothold for identifying new therapeutic targets.
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Affiliation(s)
- Zhou Chen
- The First Clinical Medical College, Lanzhou University, Lanzhou, China.,Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xiaodong Wei
- Emergency Department, Gansu Provincial Hospital, Lanzhou, China
| | - Shi Dong
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Fangfang Han
- The First Clinical Medical College, Lanzhou University, Lanzhou, China.,Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Ru He
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Wence Zhou
- The First Clinical Medical College, Lanzhou University, Lanzhou, China.,Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
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Kraszkiewicz M, Napieralska A, Wydmański J, Suwiński R, Majewski W. Evaluation of Efficacy and Tolerance of Radical Radiotherapy and Radiochemotherapy in Treatment of Locally Advanced, Unresectable Rectal Cancer. Technol Cancer Res Treat 2022; 21:15330338221086085. [PMID: 35296187 PMCID: PMC9123928 DOI: 10.1177/15330338221086085] [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] [Indexed: 12/24/2022] Open
Abstract
Background: A retrospective evaluation of tolerance and efficacy of
two schemes of neoadjuvant treatment in patients (pts) with unresectable rectal
cancer: radiochemotherapy (CRT) and radiotherapy (RT), including conventional
and accelerated hyperfractionation. Material and Method: A total of
145 consecutive pts with unresectable, locally advanced rectal cancer. The
schemes used are RT in 73 (50%) or CRT in 72 (50%). In CRT, 54 Gy in 1.8 Gy
fractions was given with chemotherapy, In the RT group, conventional
fractionation (CFRT) and hyperfractionated accelerated radiotherapy (HART). HART
was introduced at first as an alternative to CFRT, after radiobiological studies
suggesting a therapeutic gain of hyperfractionation in other cancers, and second
to administer relatively high dose needed in unresectable cancer, which is not
feasible in hypofractionation because of critical organs sensitivity to high
fraction doses (fd). HART was an alternative option in pts with medical
contraindications to chemotherapy and to shorten overall treatment time with
greater radiobiological effectiveness than CFRT. Results: Objective
response (OR) in the RT and CRT group was 60% versus 75%. Resection rate (RR) in
RT and CRT: 37% versus 65%. Tumor mobility and laparotomy-based unresectability
were significant factors for OR. Performance status (PS), tumor mobility, and
neoadjuvant treatment method were significant for RR.
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Affiliation(s)
- M Kraszkiewicz
- Maria Sklodowska-CUrie National Research Institute of Oncology Gliwice Branch, Radiotherapy Department, Gliwice, Poland
| | - A Napieralska
- Maria Sklodowska-CUrie National Research Institute of Oncology Gliwice Branch, Radiotherapy Department, Gliwice, Poland
| | - J Wydmański
- Maria Sklodowska-CUrie National Research Institute of Oncology Gliwice Branch, Radiotherapy Department, Gliwice, Poland
| | - R Suwiński
- Maria Sklodowska-CUrie National Research Institute of Oncology Gliwice Branch, II Radiotherapy and Chemotherapy Teaching Hospital, Gliwice, Poland
| | - W Majewski
- Maria Sklodowska-CUrie National Research Institute of Oncology Gliwice Branch, Radiotherapy Department, Gliwice, Poland
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Hanna-Sawires RG, Groen JV, Hamming A, Tollenaar RAEM, Mesker WE, Luelmo SAC, Vahrmeijer AL, Bonsing BA, Versteeg HH, Klok FA, Mieog JSD. Incidence, timing and risk factors of venous thromboembolic events in patients with pancreatic cancer. Thromb Res 2021; 207:134-139. [PMID: 34628229 DOI: 10.1016/j.thromres.2021.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/25/2021] [Accepted: 08/04/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Pancreatic cancer is associated with a high risk of venous thromboembolism (VTE). However, comprehensive data on incidence, timing and relevant determinants of VTE in this particular population are scarce. Current study assesses incidence, timing and predictors of VTE in pancreatic cancer through different phases of disease. METHODS All pancreatic cancer patients treated in our tertiary referral center between 2013 through 2017 were studied. Occurrence of VTE was evaluated from diagnosis through end of follow-up or death. Relevant determinants of VTE were identified in logistic regression models. Hazard ratios were calculated to evaluate impact of VTE on overall survival. RESULTS In total, 361 patients were followed for a median period of 43 months; 64 were diagnosed with VTE (18%). Most were tumor related thrombosis (59%), incidental (75%) and occurred after anti-cancer treatment had been stopped (80%), only 1.6% occurred during remission phase. Stage IV pancreatic cancer was a predictor for VTE (hazard ratio (HR) 2.46, 95% confidence interval (CI) 0.9-6.8). Biliary drainage (HR 0.52, 95%CI 0.28-0.98) and tumor resection (HR 0.45, 95%CI 0.45-1.83) were protective factors. VTE was not associated with worse survival (HR 1.3; 95% CI 0.97-1.74). CONCLUSIONS VTE in pancreatic cancer is disease-stage dependent, with 80% occurring in advanced phases of disease when patients no longer receive active treatment. We speculate that this is the main reason for the absence of a survival effect of VTE in our cohort. These practice-based findings should be taken into account when considering wide-spread introduction of primary thromboprophylaxis in patients with pancreatic cancer.
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Affiliation(s)
| | - Jesse V Groen
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Alexander Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Wilma E Mesker
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Saskia A C Luelmo
- Department of Medical Oncology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Henri H Versteeg
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands.
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9
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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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10
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Treatment of venous thromboembolism in cancer patients: The dark side of the moon. Cancer Treat Rev 2021; 96:102190. [PMID: 33812338 DOI: 10.1016/j.ctrv.2021.102190] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 02/08/2023]
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer. The risk of emergent VTE is four- to seven-fold higher in cancer patients compared to non-cancer patients. Although the therapeutic armamentarium for cancer-associated VTE has been recently implemented, anticoagulant treatment remains challenging because of the increased risk of recurrent VTE and bleeding. Several international societies and expert panels released clinical practice guidelines on VTE treatment which are mostly focused on the general cancer population. Nevertheless, recommendations for the management of VTE in patients with peculiar clinical presentations are inconsistent and remain elusive due to the lack of pertinent evidence. The challenging clinical scenarios include, among others, patients with thrombocytopenia, renal impairment, gastrointestinal cancer, primary or metastatic brain cancer, distal thrombosis of the lower extremities, catheter-related VTE, splanchnic thrombosis, incidental VTE, extreme body weight, recurrent VTE during treatment, as well as the optimal duration of anticoagulant treatment in patients with active disease who have received 3 to 6 months of anticoagulation. Herein, we present a critical overview on VTE management in these challenging clinical settings, discuss potential approaches, and include some calls to action for future clinical research.
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Suzuki T, Hori R, Takeuchi K, Yamamura R, Katoh H, Noji Y, Yamaguchi M, Fujino S. Venous Thromboembolism in Japanese Patients With Pancreatic Cancer. Clin Appl Thromb Hemost 2021; 27:10760296211051766. [PMID: 34730013 PMCID: PMC8573688 DOI: 10.1177/10760296211051766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/31/2021] [Accepted: 09/21/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related deaths in Japan. Previous studies from other countries have reported venous thromboembolism prevalence rates of 12 to 36% in patients with pancreatic cancer. In this study, we aimed to determine the incidence of VTE in patients with PDAC in Japan and compare the characteristics of patients with and without VTE. METHODS In this retrospective cohort study, clinicopathological characteristics of patients with and without concomitant VTE were compared. PATIENTS Patients with PDAC treated at Fukui Prefectural Hospital, Japan from 2010 to 2019. RESULTS The 1-year survival rate of all patients with pancreatic cancer was 40.7%. Among 432 patients with PDAC, 31 developed VTE. Seventeen (55%) patients received anticoagulant therapy. Compared with the non-VTE group, the VTE group had significantly more patients whose body mass index was >25 kg/m² (p = .035) and had a significantly higher rate of chemotherapy (p = .024). There was no significant difference in median survival time from PDAC diagnosis between the VTE and non-VTE groups. The 6-month mortality rate after VTE diagnosis was 54.8%. PDAC-related death was the most frequent cause of death, and thrombus-related death was not observed. CONCLUSION Several baseline characteristics differed between patients with and without VTE. The incidence of VTE in patients with PDAC is high. However, because the prognosis of PDAC itself remains quite poor, VTE may not have a significant effect on prognosis.
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Affiliation(s)
- Takahito Suzuki
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Reina Hori
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Kazutaka Takeuchi
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Ryo Yamamura
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Hiromasa Katoh
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Yoshihiro Noji
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Masato Yamaguchi
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
| | - Susumu Fujino
- 13607Fukui Prefectural Hospital, Fukui City, Fukui Prefecture, Japan
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12
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Li H, Yu Y, Shi Q, Chen X, Zheng P, Wang D, Tao P, Gu B, Li X, Zhang T, Xiang L, Xi D, Gao L, Maswikiti Ewetse P, Chen H. Prognostic significance of tissue factor in patients with pancreatic cancer: a systematic review protocol. BMJ Open 2020; 10:e037431. [PMID: 32928856 PMCID: PMC7490930 DOI: 10.1136/bmjopen-2020-037431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Pancreatic cancer is a highly aggressive digestive system tumour with poor prognosis. Venous thromboembolism (VTE) is a well-known complication of pancreatic cancer, and tissue factor (TF) contributes to the generation of a hypercoagulable state and thrombotic disease in pancreatic cancer. Several studies showed that an elevated TF level was related to the development of VTE and influenced the survival of patients with pancreatic cancer. Thus, we wish to conduct a systematic review of literature to clarify the prognostic significance of TF in pancreatic cancer. METHODS AND ANALYSIS Studies comparing the circulating microparticle-associated TF (MP TF) level between patients who had pancreatic cancer with and without VTE will be included to evaluate the roles of TF in VTE development. Studies comparing the survival data between patients with high TF expression and low TF expression will also be included to explore the association of TF expression with patient survival. The outcomes are plasma MP TF level and survival endpoints (overall and progression-free survival), respectively. Primary studies of any type published in English will be included. Two reviewers will search Medline, EMBASE and Cochrane databases from inception to June 2020, retrieve relevant studies, and independently select the literatures and extract data from the included studies. The quality of each included study will be assessed by the Newcastle-Ottawa Scale score. The HR and 95% CI of each study will be pooled for survival outcome, and the standardised mean difference (SMD) with 95% CIs will be used for continuous outcomes. If meta-analysis is inappropriate, the result will only be reported qualitatively. Subgroup and sensitivity analyses will be considered to identify sources of heterogeneity. The Grades of Recommendation, Assessment, Development and Evaluation method will be applied to assess the level of evidence of this systematic review. ETHICS AND DISSEMINATION There are no concerning ethical issues. The results will be published. PROSPERO REGISTRATION NUMBER CRD42019133665.
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Affiliation(s)
- Haiyuan Li
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Yang Yu
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Qianling Shi
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Xueping Chen
- Sleep Medicine Center, Gansu Provincial Hospital, Lanzhou, China
| | - Peng Zheng
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Dengfeng Wang
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Pengxian Tao
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Baohong Gu
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Xuemei Li
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Tao Zhang
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Lin Xiang
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Dayong Xi
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Lei Gao
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Paul Maswikiti Ewetse
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Hao Chen
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
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Frere C, Bournet B, Gourgou S, Fraisse J, Canivet C, Connors JM, Buscail L, Farge D. Incidence of Venous Thromboembolism in Patients With Newly Diagnosed Pancreatic Cancer and Factors Associated With Outcomes. Gastroenterology 2020; 158:1346-1358.e4. [PMID: 31843588 DOI: 10.1053/j.gastro.2019.12.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic ductal adenocarcinoma (PDAC) is associated with the highest incidence of venous thromboembolism (VTE) of any cancer type. However, little is known about risk factors for VTE or its outcomes in patients with PDAC. METHODS We collected data from a prospective, observational study performed at multiple centers in France from May 2014 through November 2018 (the Base Clinico-Biologique de l'Adénocarcinome Pancréatique [BACAP] study) linked to a database of patients with a new diagnosis of PDAC of any stage. Data were collected from 731 patients at baseline and during clinical follow-up or in the event of symptoms. The primary endpoint was the onset of VTE during follow-up. The secondary endpoints were progression-free survival (PFS) and overall survival (OS) times. RESULTS During a median follow-up of 19.3 months, 152 patients (20.79%) developed a VTE. The median time from PDAC diagnosis to the onset of VTE was 4.49 months. Cumulative incidence values of VTE were 8.07% (95% confidence interval [CI], 6.31-10.29) at 3 months and 19.21% (95% CI, 16.27-22.62) at 12 months. In multivariate analysis, PDAC primary tumor location (isthmus vs head: hazard ratio [HR], 2.06; 95% CI, 1.09-3.91; P = .027) and stage (locally advanced vs resectable or borderline: HR, 1.66; 95% CI, 1.10-2.51, P = .016; metastatic vs resectable or borderline: HR, 2.50; 95% CI, 1.64-3.79; P < .001) were independent risk factors for the onset of VTE. Patients who developed VTE during follow-up had shorter times of PFS (HR, 1.74; 95% CI, 1.19-2.54; P = .004) and OS (HR, 2.02; 95% CI, 1.57-2.60; P < .001). CONCLUSION In an analysis of data from the BACAP study, we found that frequent and early onsets of VTE after diagnoses of PDAC are associated with significant decreases in times of PFS and OS. Studies are needed to determine whether primary prophylaxis of VTE in patients with PDAC will improve morbidity and mortality related to VTE. (ClinicalTrials.gov, Number: clinicaltrials.gov as number NCT02818829).
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Affiliation(s)
- Corinne Frere
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism and Nutrition, Paris, France; Assistance Publique Hôpitaux de Paris, Department of Haematology, Pitié-Salpêtrière Hospital, Paris, France
| | - Barbara Bournet
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Sophie Gourgou
- Université de Montpellier, Institut du Cancer de Montpellier-Unité de Biométrie, Montpellier, France
| | - Julien Fraisse
- Université de Montpellier, Institut du Cancer de Montpellier-Unité de Biométrie, Montpellier, France
| | - Cindy Canivet
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Louis Buscail
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Dominique Farge
- Université de Paris, Institut Universitaire d'Hématologie, Paris, France; Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, Paris, France; Department of Medicine, McGill University, Montreal, Québec, Canada.
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14
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Farge D, Bournet B, Conroy T, Vicaut E, Rak J, Zogoulous G, Barkun J, Ouaissi M, Buscail L, Frere C. Primary Thromboprophylaxis in Pancreatic Cancer Patients: Why Clinical Practice Guidelines Should Be Implemented. Cancers (Basel) 2020; 12:E618. [PMID: 32155940 PMCID: PMC7139861 DOI: 10.3390/cancers12030618] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/13/2022] Open
Abstract
Exocrine pancreatic ductal adenocarcinoma, simply referred to as pancreatic cancer (PC) has the worst prognosis of any malignancy. Despite recent advances in the use of adjuvant chemotherapy in PC, the prognosis remains poor, with fewer than 8% of patients being alive at 5 years after diagnosis. The prevalence of PC has steadily increased over the past decades, and it is projected to become the second-leading cause of cancer-related death by 2030. In this context, optimizing and integrating supportive care is important to improve quality of life and survival. Venous thromboembolism (VTE) is a common but preventable complication in PC patients. VTE occurs in one out of five PC patients and is associated with significantly reduced progression-free survival and overall survival. The appropriate use of primary thromboprophylaxis can drastically and safely reduce the rates of VTE in PC patients as shown from subgroup analysis of non-PC targeted placebo-controlled randomized trials of cancer patients and from two dedicated controlled randomized trials in locally advanced PC patients receiving chemotherapy. Therefore, primary thromboprophylaxis with a Grade 1B evidence level is recommended in locally advanced PC patients receiving chemotherapy by the International Initiative on Cancer and Thrombosis clinical practice guidelines since 2013. However, its use and potential significant clinical benefit continues to be underrecognized worldwide. This narrative review aims to summarize the main recent advances in the field including on the use of individualized risk assessment models to stratify the risk of VTE in each patient with individual available treatment options.
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Affiliation(s)
- Dominique Farge
- Institut Universitaire d’Hématologie, Université de Paris, EA 3518, F-75010 Paris, France
- Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, F-75010 Paris, France
- Department of Medicine, McGill University, Montreal, Québec, QC H4A 3J1, Canada
| | - Barbara Bournet
- University of Toulouse, F-31059 Toulouse, France; (B.B.); (L.B.)
- CHU de Toulouse, Department of Gastroenterology and Pancreatology, F-31059 Toulouse, France
| | - Thierry Conroy
- Institut de Cancérologie de Lorraine, Department of Medical Oncology, Université de Lorraine, APEMAC, EA4360, F-54519 Vandoeuvre-lès-Nancy, France;
| | - Eric Vicaut
- Department of Biostatistics, Université de Paris, F-75010 Paris, France;
- Assistance Publique Hôpitaux de Paris, Department of Biostatistics, Fernand Widal Hospital, F-75010 Paris, France
| | - Janusz Rak
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - George Zogoulous
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - Jefferey Barkun
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, and Hepatic Surgery, and Hepatic Transplantation, Trousseau Hospital, CHRU Trousseau, F-37170 Chambray-les-Tours, France;
| | - Louis Buscail
- University of Toulouse, F-31059 Toulouse, France; (B.B.); (L.B.)
- CHU de Toulouse, Department of Gastroenterology and Pancreatology, F-31059 Toulouse, France
| | - Corinne Frere
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166, GRC 27 GRECO, F-75013 Paris, France;
- Assistance Publique Hôpitaux de Paris, Department of Haematology, Pitié-Salpêtrière Hospital, F-75013 Paris, France
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Godinho J, Casa‐Nova M, Moreira‐Pinto J, Simões P, Paralta Branco F, Leal‐Costa L, Faria A, Lopes F, Teixeira JA, Passos‐Coelho JL. ONKOTEV Score as a Predictive Tool for Thromboembolic Events in Pancreatic Cancer-A Retrospective Analysis. Oncologist 2020; 25:e284-e290. [PMID: 32043787 PMCID: PMC7011666 DOI: 10.1634/theoncologist.2019-0510] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 09/30/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a frequent complication in patients with cancer and causes considerable morbidity and mortality. The risk of VTE is higher in patients with pancreatic cancer and is often associated with treatment delays or interruptions. Recently, the ONKOTEV score was proposed as a VTE risk predictor model for patients with cancer, but its validation is still ongoing. PATIENTS AND METHODS We conducted a retrospective study to determine the incidence of VTE and to evaluate the ONKOTEV score as a VTE predictive tool in a population of patients with pancreatic cancer. RESULTS Between February 2012 and May 2017, 165 patients were included in the study. The median age was 73 years, 45.5% of patients were female, and 55.8% had stage IV disease. Fifty-one patients had a VTE (30.9%); 23.5% had pulmonary embolism, 25.5% had deep venous thrombosis, and 51.0% had visceral VTE (VsT). At a median follow-up time of 6.3 months, cumulative incidence of VTE was less than 10% for ONKOTEV scores 0 or 1 and approximately 40% and 70% for scores 2 and ≥3, respectively. CONCLUSION The high VTE incidence observed in this study is consistent with prior reports. Patients at high risk for VTE with no increase in hemorrhagic risk should be considered for primary thromboprophylaxis. The ONKOTEV score may stratify VTE risk in patients with pancreatic cancer, with ONKOTEV score ≥2 being associated with a higher VTE occurrence. IMPLICATIONS FOR PRACTICE Venous thromboembolism (VTE) is a frequent complication of patients with pancreatic cancer and causes considerable morbidity, treatment delays or interruptions, and mortality. Thromboprophylaxis is not used routinely in ambulatory patients. Tools to stratify the risk of VTE are important to help select patients who may benefit from thromboprophylaxis. Recently, the ONKOTEV score was proposed as a VTE risk predictor model for patients with cancer, but its validation is still ongoing. In this patient series, ONKOTEV score ≥2 was associated with high VTE occurrence and may stratify VTE risk in patients with pancreatic cancer, suggesting that ONKOTEV can be considered to select patients with pancreatic cancer for primary thromboprophylaxis.
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Affiliation(s)
| | | | | | | | | | | | - Ana Faria
- Hospital Beatriz ÂngeloLouresPortugal
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The relationship between pancreatic cancer and hypercoagulability: a comprehensive review on epidemiological and biological issues. Br J Cancer 2019; 121:359-371. [PMID: 31327867 PMCID: PMC6738049 DOI: 10.1038/s41416-019-0510-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 05/13/2019] [Accepted: 05/28/2019] [Indexed: 12/15/2022] Open
Abstract
It has long been recognised that pancreatic cancer induces a hypercoagulable state that may lead to clinically apparent thrombosis. Although the relationship between pancreatic cancer and hypercoagulability is well described, the underlying pathological mechanism(s) and the interplay between these pathways remain a matter of intensive study. This review summarises existing data on epidemiology and pathogenesis of thrombotic complications in pancreatic cancer with a particular emphasis on novel pathophysiological pathways. Pancreatic cancer is characterised by high tumoural expression of tissue factor, activation of leukocytes with the release of neutrophil extracellular traps, the dissemination of tumour-derived microvesicles that promote hypercoagulability and increased platelet activation. Furthermore, other coagulation pathways probably contribute to these processes, such as those that involve heparanase, podoplanin and hypofibrinolysis. In the era in which heparin and its derivatives—the currently recommended therapy for cancer-associated thrombosis—might be superseded by direct oral anticoagulants, novel data from mouse models of cancer-associated thrombosis suggest the possibility of future personalised therapeutic approaches. In this dynamic era for cancer-associated thrombosis, the discovery of novel prothrombotic and proinflammatory mechanisms will potentially uncover pharmacological targets to prevent and treat thrombosis without adversely affecting haemostasis.
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