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Pavlovic D, Niciforovic D, Markovic M, Papic D. Cancer-Associated Thrombosis: Epidemiology, Pathophysiological Mechanisms, Treatment, and Risk Assessment. Clin Med Insights Oncol 2023; 17:11795549231220297. [PMID: 38152726 PMCID: PMC10752082 DOI: 10.1177/11795549231220297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023] Open
Abstract
Cancer patients represent a growing population with drastically difficult care and a lowered quality of life, especially due to the heightened risk of vast complications. Thus, it is well established so far that one of the most prominent complications in individuals with cancer is venous thromboembolism. Since there are various improved methods for screening and diagnosing cancer and its complications, the incidence of cancer-associated thrombosis has been on the rise in recent years. Therefore, the high mortality and morbidity rates among these patients are not a surprise. Consequently, there is an excruciating need for understanding the mechanisms behind this complex process, as well as the imperative for adequate analysis and application of the most suitable steps for cancer-associated thrombosis prevention. There are various and numerous mechanisms offering potential answers to cancer-associated thrombosis, some of which have already been elucidated in various preclinical and clinical scenarios, yet further and more elaborate studies are crucial to understanding and preventing this complex and harsh clinical entity. This article elaborates on the growing incidence, mortality, morbidity, and risk factors of cancer-associated thrombosis while emphasizing the pathophysiological mechanisms in the light of various types of cancer in patients and summarizes the most novel therapy and prevention guidelines recommendations.
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Affiliation(s)
- Dragica Pavlovic
- Department of Genetics, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Danijela Niciforovic
- Center for Internal Oncology, University Clinical Center Kragujevac, Kragujevac, Serbia
| | - Marina Markovic
- Center for Internal Oncology, University Clinical Center Kragujevac, Kragujevac, Serbia
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Dragana Papic
- Department of Genetics, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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Zhao J, Ma Z, Li H, Sun D, Hu Y, Zhang C, Zhang Y. Risks of cardiovascular toxicities associated with ALK tyrosine kinase inhibitors in patients with non-small-cell lung cancer: a meta-analysis of randomized control trials. Expert Opin Drug Saf 2023; 22:581-588. [PMID: 36803384 DOI: 10.1080/14740338.2023.2182284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/30/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Anaplastic lymphoma kinases (ALK) tyrosine kinase inhibitors (TKIs) are effective and safe targeted therapies used in advanced ALK-positive non-small cell lung cancers (NSCLC). However, ALK-TKIs associated cardiovascular toxicities in patients with ALK-positive NSCLCremain incompletely characterized. We conducted the first meta-analysis to investigate this. RESEARCH DESIGN AND METHODS To determine the cardiovascular toxicities associated with these agents, we carried out a meta-analysis comparing ALK-TKIs with chemotherapy and a meta-analysis comparing crizotinib with other ALK-TKIs. Statistical analysis was conducted to calculate the RRs and 95% confidence intervals (CIs) by using either random effects or fixed-effect models according to the heterogeneity of the included studies. RESULTS A total of 11 studies (2855 patients) were included. ALK-TKIs ranked to have more severe cardiovascular toxicities than chemotherapy (RR 5.03, 95% CI 1.97-12.84, P = 0.0007) . Compared with other ALK-TKIs, increased risks of cardiac disorders and VTEs associated with crizotinib were found (cardiac disorders RR 1.75, 95% CI 1.07-2.86, P = 0.03; risk of VTEs RR 3.97, 95% CI 1.69-9.31, P = 0.002; respectively). CONCLUSION ALK-TKIs were associated with higher risks of cardiovascular toxicities. Special attention should be given to the risks of cardiac disorders and VTEs related to crizotinib therapy.
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Affiliation(s)
- Jin Zhao
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, Hebei, China
| | - Zhuo Ma
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, Hebei, China
| | - Hao Li
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, Hebei, China
| | - Dan Sun
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, Hebei, China
| | - Yi Hu
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, Hebei, China
| | - Chen Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, Hebei, China
| | - Yuhui Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, Hebei, China
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Lin M, Lu Y, Yu Q, Chen Z, Peng J, Cai X. Common genetic driver mutation in NSCLC and their association with thromboembolic events: A retrospective study. Lung Cancer 2022; 172:29-34. [PMID: 35986977 DOI: 10.1016/j.lungcan.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/15/2022] [Accepted: 06/19/2022] [Indexed: 11/11/2022]
Abstract
UNLABELLED This retrospective study aimed to estimate the incidence, risk factors of thromboembolism events (TEs) in non-small cell lung cancer patients harboring common gene mutation, and evaluate a genetic link between oncogenes and the risk of TEs in Asian patients with NSCLC. METHODS Univariate and multivariate Cox's proportional hazards regression models were used to identify the strongest predictors of TE development and evaluate the risk of TE in patients with different gene statuses of NSCLC patients. RESULTS In univariate and multivariate COX analysis, patient with squamous cell carcinoma (HR 3.01, 95% CI: [1.06,8.56]; p = 0.039), multi-site metastases (HR: 2.72; 95% CI: [1.08,6.92]; p = 0.032) or high white blood cell (WBC) (HR 3.24, 95% CI: [1.46,7.22]; p = 0.004), less hemoglobin (HGB) (HR 4.89, 95% CI: [1.90,12.64]; p = 0.001), are at higher risk of thrombosis. At the molecular level, ROS and ALK rearrangement is highly associated with TE development, with HR of 4.04 (95%CI: [1.54,10.58]; p = 0.005) and HR of 3.57 (95% CI: [1.01,12.66]; p = 0.049) in univariate analysis, and even higher in multivariate analysis. EGFR mutations seem to be a protective factor against TE in univariate analyses (HR:0.28, 95%CI [0.12,0.65], p = 0.003) but are not statistically significant in the multivariate model. No correlation between KRAS mutations and TE events in both models. Besides, a numerically higher cumulative incidence of thrombosis event was observed in patients who used TKI (HR 1.473; 95% CI: [0.682, 3.181]; p = 0.32). CONCLUSION Our study demonstrated that driver gene mutation may increase the risk of thrombosis in non-small cell lung cancer patients. The presence of ALK/ROS rearrangements in our study is associated with an approximately threefold to fourfold increase in thrombosis risk in NSCLC patients. For advanced-stage patients who used TKI, an increased incidence of thrombosis risk and shorter follow-up were observed.
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Affiliation(s)
- Miaozhen Lin
- Department of VIP Inpatient, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangzhou, China
| | - Yujuan Lu
- Department of VIP Inpatient, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangzhou, China
| | - Qiwen Yu
- Department of Oncology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou China
| | - Zebin Chen
- Department of Oncology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou China
| | - Jiayu Peng
- Department of Oncology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou China
| | - Xiuyu Cai
- Department of VIP Inpatient, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangzhou, China.
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Yan AR, Samarawickrema I, Naunton M, Peterson GM, Yip D, De Rosa S, Mortazavi R. Risk Factors and Prediction Models for Venous Thromboembolism in Ambulatory Patients with Lung Cancer. Healthcare (Basel) 2021; 9:778. [PMID: 34205695 PMCID: PMC8233898 DOI: 10.3390/healthcare9060778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/13/2021] [Accepted: 06/17/2021] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism (VTE) is a significant cause of mortality in patients with lung cancer. Despite the availability of a wide range of anticoagulants to help prevent thrombosis, thromboprophylaxis in ambulatory patients is a challenge due to its associated risk of haemorrhage. As a result, anticoagulation is only recommended in patients with a relatively high risk of VTE. Efforts have been made to develop predictive models for VTE risk assessment in cancer patients, but the availability of a reliable predictive model for ambulate patients with lung cancer is unclear. We have analysed the latest information on this topic, with a focus on the lung cancer-related risk factors for VTE, and risk prediction models developed and validated in this group of patients. The existing risk models, such as the Khorana score, the PROTECHT score and the CONKO score, have shown poor performance in external validations, failing to identify many high-risk individuals. Some of the newly developed and updated models may be promising, but their further validation is needed.
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Affiliation(s)
- Ann-Rong Yan
- School of Health Sciences, Faculty of Health, University of Canberra, Canberra 2617, Australia; (A.-R.Y.); (M.N.); (G.M.P.); (D.Y.)
| | - Indira Samarawickrema
- School of Nursing, Midwifery and Public Health, Faculty of Health, University of Canberra, Canberra 2617, Australia;
| | - Mark Naunton
- School of Health Sciences, Faculty of Health, University of Canberra, Canberra 2617, Australia; (A.-R.Y.); (M.N.); (G.M.P.); (D.Y.)
| | - Gregory M. Peterson
- School of Health Sciences, Faculty of Health, University of Canberra, Canberra 2617, Australia; (A.-R.Y.); (M.N.); (G.M.P.); (D.Y.)
- College of Health and Medicine, University of Tasmania, Hobart 7005, Australia
| | - Desmond Yip
- School of Health Sciences, Faculty of Health, University of Canberra, Canberra 2617, Australia; (A.-R.Y.); (M.N.); (G.M.P.); (D.Y.)
- Department of Medical Oncology, The Canberra Hospital, Garran 2605, Australia
- ANU Medical School, Australian National University, Canberra 0200, Australia
| | - Salvatore De Rosa
- Department of Medical and Surgical Science, Magna Graecia University, 88100 Catanzaro, Italy;
| | - Reza Mortazavi
- School of Health Sciences, Faculty of Health, University of Canberra, Canberra 2617, Australia; (A.-R.Y.); (M.N.); (G.M.P.); (D.Y.)
- Prehab Activity Cancer Exercise Survivorship Research Group, Faculty of Health, University of Canberra, Canberra 2617, Australia
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Zhu VW, Zhao JJ, Gao Y, Syn NL, Zhang SS, Ou SHI, Bauer KA, Nagasaka M. Thromboembolism in ALK+ and ROS1+ NSCLC patients: A systematic review and meta-analysis. Lung Cancer 2021; 157:147-155. [PMID: 34049720 DOI: 10.1016/j.lungcan.2021.05.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/30/2021] [Accepted: 05/17/2021] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Increased thromboembolism (TE) has been reported in ALK+ and ROS1+ non-small cell lung cancer (NSCLC). MATERIALS AND METHODS Odds ratios (OR) and hazard ratios (HR) of TE were calculated from meta-analysis and time-to-event analysis respectively for either ALK+ or ROS1+ NSCLC patients. RESULTS We identified eight studies (766 ALK+, 143 ROS1+, 2314 non-ALK+ and non-ROS1+ NSCLC patients) for the meta-analysis. For ALK+ NSCLC, the pooled OR was 2.00 (95% CI: 1.60-2.50) for total TE (TTE) by random-effects model, 2.10 (95% CI: 1.70-2.60) for venous thromboembolism (VTE), and 1.24 (95% CI: 0.80-1.91) for arterial thromboembolism (ATE). For ROS1+ NSCLC, the pooled OR was 3.08 (95% CI: 1.95-4.86) for TTE, and 3.15 (95% CI: 1.83-5.43) for VTE. Six studies (739 ALK+, 137 ROS1+, 561 EGFR+, 714 "wildtype" NSCLC patients) were included in the time-to-event analysis. The TTE incidence rate was 17.4 (95% CI: 15.3-19.5) per 100 pateint-years for ALK+ NSCLC, and 32.1 (95% CI: 24.6-39.6) per 100 patient-years for ROS1+ NSCLC with a 50 % cumulative incidence rate at year 3 of diagnosis. HR for TTE was 2.35 (95% CI: 1.90-2.92, p < 0.001) and 3.23 (95% CI: 2.40-4.34, p < 0.001) for ALK+ and ROS1+ NSCLC, respectively. Comparing ROS1+ NSCLC to ALK+ NSCLC, HR for TTE was 1.37 (95% CI: 1.05-1.79, p = 0.020). CONCLUSIONS ALK+ and ROS1+ NSCLC patients had an increased risk of TE. ROS1+ NSCLC had further increased risk of TE over ALK+ NSCLC.
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Affiliation(s)
- Viola W Zhu
- University of California Irvine School of Medicine, Department of Medicine, Orange, CA, USA; Chao Family Comprehensive Cancer Center, Orange, CA, USA
| | - Joseph J Zhao
- National University of Singapore Yong Loo Lin School of Medicine, Singapore
| | - Yanfei Gao
- Dalian Best Biotechnology Ltd, Beijing, China(2)
| | - Nicholas L Syn
- National University of Singapore Yong Loo Lin School of Medicine, Singapore
| | - Shannon S Zhang
- University of California Irvine School of Medicine, Department of Medicine, Orange, CA, USA
| | - Sai-Hong Ignatius Ou
- University of California Irvine School of Medicine, Department of Medicine, Orange, CA, USA; Chao Family Comprehensive Cancer Center, Orange, CA, USA.
| | - Kenneth A Bauer
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Misako Nagasaka
- Department of Medical Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA; Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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Liu Y, Wang W, Wu F, Gao G, Xu J, Li X, Zhao C, Yang S, Mao S, Pan Y, Jia K, Shao C, Chen B, Ren S, Zhou C. High discrepancy in thrombotic events in non-small cell lung cancer patients with different genomic alterations. Transl Lung Cancer Res 2021; 10:1512-1524. [PMID: 33889526 PMCID: PMC8044490 DOI: 10.21037/tlcr-20-1290] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Acute complications, such as venous thromboembolism (VTE), are common in patients with advanced severe lung cancers. However, current VTE risk scores cannot adequately identify high-risk patients with non-small cell lung cancer (NSCLC). The study proposed to elucidated the incidence of thromboembolism (TE) in patients with different oncogenic aberrations and the impact of these aberrations on the efficacy of targeted therapy in patients with NSCLC. Methods A systemic review was conducted in Web of Science, PubMed, Embase and the Cochrane Library to evaluate the incidence of TE in different molecular subtypes of NSCLC. Data from patients diagnosed of advanced NSCLC who harboring anaplastic lymphoma kinase (ALK) or ROS proto-oncogene 1 receptor tyrosine kinase (ROS1) rearrangements since 2016 to 2019 were also retrospectively collected. A meta-analysis with random-effects model, sensitivity analysis and publication bias were performed. The principal summary measure was incidence of thrombotic events in NSCLC patients. And the efficacy of tyrosine kinase inhibitor (TKI) therapy was compared between the two subgroups. Results A total of 5,767 cases from 20 studies were included in the analysis of the incidence of thrombosis in patients with different oncogenic alterations. The pooled analysis showed a higher risk of thrombosis in ROS1-fusion types (41%, 95% CI: 35-47%) and ALK-fusion types (30%, 95% CI: 24-37%) than in EGFR-mutation (12%, 95% CI: 8-17%), KRAS-mutation (25%, 95% CI: 13-50%), and wild-type (14%, 95% CI: 10-20%) cases. A high prevalence of thrombosis (ALK: 24.4%; ROS1: 32.6%) was observed in the Shanghai Pulmonary Hospital (SPH) cohort of 224 patients with ALK or ROS1 fusion. Furthermore, patients with embolism had significantly shorter progression-free survival (PFS) after TKI therapy than those without embolism, both in the ALK+ cohort (5.6 vs. 12.9 months, P<0.0001) and in the ROS1+ cohort (9.6 vs. 17.6 months, P=0.0481). Conclusions NSCLC patients with ALK/ROS1 rearrangements are more likely to develop thrombosis than patients with other oncogenic alterations. Thrombosis may also be associated with an inferior response and PFS after TKI therapy.
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Affiliation(s)
- Yiwei Liu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wanying Wang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Fengying Wu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Guanghui Gao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jian Xu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xuefei Li
- Department of Lung Cancer and Immunology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chao Zhao
- Department of Lung Cancer and Immunology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shuo Yang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shiqi Mao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yingying Pan
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Keyi Jia
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chuchu Shao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Bin Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shengxiang Ren
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Caicun Zhou
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
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Yang S, Yang L, Wu Y, Zhang C, Wang S, Ma N, Wang L, Wang Q. Anaplastic lymphoma kinase rearrangement may increase the incidence of venous thromboembolism by increasing tissue factor expression in advanced lung adenocarcinoma. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1307. [PMID: 33209887 PMCID: PMC7661863 DOI: 10.21037/atm-20-6619] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Patients with lung cancer are at an increased risk for venous thromboembolism (VTE). Approximately 8–15% of patients with advanced non-small-cell lung cancer (NSCLC) experience a VTE throughout the course of the disease. However, the incidence of VTE in different NSCLC molecular subtypes is rarely reported, although there are significant differences in clinical feature and prognosis. Tissue factor (TF) expressed in many solid tumors could trigger the downstream coagulation cascade and lead to thrombin generation and clot formation. Methods In the present study, retrospective data were obtained from electronic medical records at Henan Cancer Hospital in China between January 2015 and January 2017. Advanced lung adenocarcinoma patients with anaplastic lymphoma kinase (ALK) rearrangement, epidermal growth factor receptor (EGFR) mutation and both negative were included in the present study. The incidence of VTE of these patients was calculated. We then randomly selected ALK-rearrangement-positive and -negative lung adenocarcinoma tissues (n=29 and n=26, respectively) and detected TF protein expression via immunohistochemistry. Results At a median follow up of 2.5 years, 5.85% (n=30/513) patients with advanced lung adenocarcinoma experienced VTE. Compared to patients with EGFR mutation (n=11/218, 5.05%) or both negative (n=13/266, 4.89%), patients with ALK-rearrangement were more likely to develop VTE (n=6/29, 20.69%; P=0.006, P=0.004; respectively). In ALK-rearrangement-positive tissues, 41.67% (n=10/24) had a high TF protein expression; the incidence was significantly higher than the TF protein expression in ALK-negative tissues (11.54%, n=3/26, P=0.015). Conclusions ALK-rearrangement-positive NSCLC patients are more likely to develop VTE; this might be due to a higher TF expression in tumor tissues.
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Affiliation(s)
- Sen Yang
- Department of Internal Medicine, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Li Yang
- Department of Internal Medicine, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Yufeng Wu
- Department of Internal Medicine, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Cuicui Zhang
- Department of Internal Medicine, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Shuai Wang
- Department of Internal Medicine, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Nan Ma
- Henan Academy of Medical Sciences, Zhengzhou, China
| | - Li Wang
- Henan Academy of Medical Sciences, Zhengzhou, China
| | - Qiming Wang
- Department of Internal Medicine, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
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Leiva O, Connors JM, Al-Samkari H. Impact of Tumor Genomic Mutations on Thrombotic Risk in Cancer Patients. Cancers (Basel) 2020; 12:cancers12071958. [PMID: 32707653 PMCID: PMC7409200 DOI: 10.3390/cancers12071958] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 12/19/2022] Open
Abstract
Venous thromboembolism (VTE) is common in patients with cancer and is an important contributor to morbidity and mortality in these patients. Early thromboprophylaxis initiated only in those cancer patients at highest risk for VTE would be optimal. Risk stratification scores incorporating tumor location, laboratory values and patient characteristics have attempted to identify those patients most likely to benefit from thromboprophylaxis but even well-validated scores are not able to reliably distinguish the highest-risk patients. Recognizing that tumor genetics affect the biology and behavior of malignancies, recent studies have explored the impact of specific molecular aberrations on the rate of VTE in cancer patients. The presence of certain molecular aberrations in a variety of different cancers, including lung, colon, brain and hematologic tumors, have been associated with an increased risk of VTE and arterial thrombotic events. This review examines the findings of these studies and discusses the implications of these findings on decisions relating to thromboprophylaxis use in the clinical setting. Ultimately, the integration of tumor molecular genomic information into clinical VTE risk stratification scores in cancer patients may prove to be a major advancement in the prevention of cancer-associated thrombosis.
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02215, USA;
- Harvard Medical School, Boston, MA 02215, USA;
| | - Jean M. Connors
- Harvard Medical School, Boston, MA 02215, USA;
- Hematology Division, Brigham and Women’s Hospital, Boston, MA 02215, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA 02215, USA;
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
- Correspondence: ; Tel.: +1-617-643-6214
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ALK/ROS1 rearrangements: A real hallmark for thromboembolic events in cancer patients? Thromb Res 2020; 194:176-177. [PMID: 32788112 DOI: 10.1016/j.thromres.2020.06.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/17/2020] [Accepted: 06/23/2020] [Indexed: 01/25/2023]
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Al-Samkari H, Leiva O, Dagogo-Jack I, Shaw A, Lennerz J, Iafrate AJ, Bendapudi PK, Connors JM. Impact of ALK Rearrangement on Venous and Arterial Thrombotic Risk in NSCLC. J Thorac Oncol 2020; 15:1497-1506. [PMID: 32437899 DOI: 10.1016/j.jtho.2020.04.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Clinical venous thromboembolism (VTE) risk prediction scores, such as the Khorana Risk Score, perform poorly in NSCLC, possibly because the tumor molecular subtype is omitted. Previous studies suggest a possible increased VTE risk in ALK-rearranged NSCLC, but data are conflicting. METHODS We performed a retrospective cohort study of patients with advanced-stage NSCLC diagnosed between 2009 and 2019. Multivariable, time-to-event analyses modeling the risk of first venous or arterial thrombosis in ALK and non-ALK NSCLC groups, controlling for covariates known to impact thrombosis risk (15 in VTE model and 17 in arterial thrombosis model), were performed using Cox proportional hazards regression and competing-risks regression. Multivariable negative binomial regression modeled the total VTE rate. RESULTS A total of 422 patients with ALK-rearranged and 385 patients with non-ALK-rearranged NSCLC were included. Patients with an ALK rearrangement were younger, had better performance status, and had lower rates of most thrombotic risk factors but had significantly higher rates of initial VTE (42.7% versus 28.6%, p < 0.0001), recurrent VTE (13.5% versus 3.1%, p < 0.0001), and similar rates of arterial thrombosis (5.0% versus 4.4%, p = 0.71) compared with non-ALK NSCLC. VTE risk attributable to ALK was significant (Cox model: hazard ratio 3.70, [95% confidence interval [CI]: 2.51-5.44, p < 0.001], competing risks: subhazard ratio 3.91 [95% CI: 2.55-5.99, p < 0.001]). Negative binomial modeling revealed higher VTE rates in patients with an ALK rearrangement (incidence rate ratio 2.47 [95% CI: 1.72-3.55, p < 0.001]). The OR for recurrent VTE was 4.85 (95% CI: 2.60-9.52, p < 0.001). Arterial thrombosis risk attributable to ALK was significant (Cox model: hazard ratio 3.15 [95% CI: 1.18-8.37, p = 0.021], competing risks: subhazard ratio 2.80 [95% CI: 1.06-7.43, p = 0.038]). CONCLUSIONS In time-to-event analyses controlling for thrombosis risk factors, the ALK rearrangement conferred a fourfold increase in VTE risk and a threefold increase in arterial thrombosis risk in NSCLC. These patients may benefit from pharmacologic thromboprophylaxis.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Orly Leiva
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ibiayi Dagogo-Jack
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Alice Shaw
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Jochen Lennerz
- Harvard Medical School, Boston, Massachusetts; Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital, Boston, Massachusetts
| | - Anthony J Iafrate
- Harvard Medical School, Boston, Massachusetts; Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital, Boston, Massachusetts
| | - Pavan K Bendapudi
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Jean M Connors
- Harvard Medical School, Boston, Massachusetts; Hematology Division, Brigham and Women's Hospital, Boston, Massachusetts
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11
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Alexander M, Pavlakis N, John T, O'Connell R, Kao S, Hughes BGM, Lee A, Hayes SA, Howell VM, Clarke SJ, Millward M, Burbury K, Solomon B, Itchins M. A multicenter study of thromboembolic events among patients diagnosed with ROS1-rearranged non-small cell lung cancer. Lung Cancer 2020; 142:34-40. [PMID: 32087434 DOI: 10.1016/j.lungcan.2020.01.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study aimed to describe the longitudinal thromboembolism (TE) risk relative to the natural history of disease and clinical course of ROS1 rearranged non-small cell lung cancer (NSCLC). MATERIALS AND METHODS Cases of ROS1-rearranged NSCLC from six Australian hospitals were pooled and evaluated for incidence, timing, predictors and outcomes of venous or arterial TE, as well as objective response rate (ORR) to active therapy and overall survival (OS). RESULTS Of 42 patients recruited, 20 (48%) experienced TE; one (2%) arterial, 13 (31%) a pulmonary emboli (PE), and 12 (29%) a deep vein thrombosis. Among those with TE, six (30%) experienced multiple events, three as concurrent and three as recurrent diagnoses. The cumulative incidence of TE over time, adjusted for death as a competing risk factor, approached 50%. TE occurred prior to, during and post the peri-diagnostic period and occurred irrespective of treatment strategy. A thrombophilia was identified in n = 3/10 (30%) cases screened: in two factor V Leiden and in one anti-thrombin III (ATIII) deficiency. Median OS was 21.3 months in those with TE vs. 28.8 months in those without; hazard ratio 1.16 (95%CI 0.43-3.15). Respective ORR to first-line therapy with TE was 50% vs. 44% without TE in the chemotherapy arm and 67% vs. 50% in the targeted therapy arm. CONCLUSION In the rare cancer subtype, ROS1, these real-world data demonstrate sustained TE risk beyond the diagnostic period irrespective of therapeutic strategy. High incidence of PE, concurrent TE, and recurrent TE warrant validation in larger cohorts. Consideration of primary thromboprophylaxis in ROS1 populations is recommended.
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Affiliation(s)
- Marliese Alexander
- Department of Pharmacy, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.
| | - Nick Pavlakis
- Bill Walsh Translational Research Laboratory, Kolling Institute Medical Institute of Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia; Northern Cancer Institute, St Leonards, New South Wales, Australia; Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Thomas John
- Medical Oncology Unit, Olivia Newton John Cancer and Wellness Centre, Austin Health, Melbourne, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia; Department of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rachel O'Connell
- NHMRC Clinical Trial Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Steven Kao
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Brett G M Hughes
- Department of Medical Oncology, The Prince Charles Hospital, Chermside West, Queensland, Australia; School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Adrian Lee
- Bill Walsh Translational Research Laboratory, Kolling Institute Medical Institute of Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia; Northern Cancer Institute, St Leonards, New South Wales, Australia; Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Sarah A Hayes
- Bill Walsh Translational Research Laboratory, Kolling Institute Medical Institute of Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
| | - Viive M Howell
- Bill Walsh Translational Research Laboratory, Kolling Institute Medical Institute of Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
| | - Stephen J Clarke
- Bill Walsh Translational Research Laboratory, Kolling Institute Medical Institute of Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia; Northern Cancer Institute, St Leonards, New South Wales, Australia; Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Michael Millward
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia; Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Kate Burbury
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin Solomon
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia; Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Malinda Itchins
- Bill Walsh Translational Research Laboratory, Kolling Institute Medical Institute of Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia; Northern Cancer Institute, St Leonards, New South Wales, Australia; Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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12
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ROS1-rearranged Non-small-cell Lung Cancer is Associated With a High Rate of Venous Thromboembolism: Analysis From a Phase II, Prospective, Multicenter, Two-arms Trial (METROS). Clin Lung Cancer 2019; 21:15-20. [PMID: 31607443 DOI: 10.1016/j.cllc.2019.06.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/09/2019] [Accepted: 06/07/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with cancer are at increased risk for venous thromboembolism (VTE), and 8% to 15% of patients with advanced non-small-cell lung cancer (NSCLC) experience a VTE event during the course of their disease. The incidence of VTE in molecularly defined NSCLC subgroups is still unclear. In this study, we investigated the incidence and the clinical correlates of VTE in patients with ROS1-rearranged NSCLC enrolled in the METROS trial (NCT02499614). PATIENTS AND METHODS The METROS trial is a prospective phase II study designed to assess efficacy, safety, and tolerability of crizotinib in patients with pre-treated metastatic NSCLC ROS1 rearrangement (cohort A) or with MET amplification or MET exon 14 mutation (cohort B). Patients with ROS1-rearranged NSCLC enrolled within cohort A and the expansion cohort of the trial were included in the primary analysis. RESULTS Among 48 patients with ROS1-rearranged NSCLC enrolled in the METROS study, 20 (41.6%) of 48 had at least 1 VTE event. Among them, 7 (35%) of 20 patients had ≥ 2 VTE events. VTE events consisted of pulmonary embolism (46.4%), deep vein thrombosis (39.2%), renal vein thrombosis (7.1%), internal jugular thrombosis (3.5%), and peripheral inserted central catheter-related thrombosis (3.5%). VTE events occurred at disease progression in 35.7% of cases, at diagnosis in 32.1% of cases, and during chemotherapy or crizotinib in 17.8% and 14.2%, respectively. CONCLUSION The incidence of VTE is 3- to 5-fold higher in patients harboring ROS1-rearrangment than previously observed for the general population with NSCLC. Larger studies are warranted to confirm our findings and determine whether the molecular profile of NSCLC should be incorporated into a risk-stratification tool and decision-making algorithm for VTE diagnosis and prophylaxis.
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13
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Lee A, Howell VM, Itchins M, Wheeler HR, Pavlakis N. ROS1-Rearranged Non-Small-Cell Lung Cancer, Factor V Leiden, and Recurrent Venous Thromboses. Clin Lung Cancer 2018; 19:457-459. [PMID: 29945753 DOI: 10.1016/j.cllc.2018.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/15/2018] [Accepted: 05/28/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Adrian Lee
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, Australia; Northern Sydney Cancer Centre, Northern Sydney Local Health District, Royal North Shore Hospital, St Leonards, Australia; Sydney Medical School, Northern Clinical School, University of Sydney, Sydney, Australia
| | - Viive M Howell
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, Australia; Sydney Medical School, Northern Clinical School, University of Sydney, Sydney, Australia.
| | - Malinda Itchins
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, Australia; Sydney Medical School, Northern Clinical School, University of Sydney, Sydney, Australia
| | - Helen R Wheeler
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, Australia; Northern Sydney Cancer Centre, Northern Sydney Local Health District, Royal North Shore Hospital, St Leonards, Australia; Sydney Medical School, Northern Clinical School, University of Sydney, Sydney, Australia
| | - Nick Pavlakis
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, Royal North Shore Hospital, St Leonards, Australia; Northern Sydney Cancer Centre, Northern Sydney Local Health District, Royal North Shore Hospital, St Leonards, Australia; Sydney Medical School, Northern Clinical School, University of Sydney, Sydney, Australia
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