Prognostic value of computed tomography pulmonary angiography indices in patients with cancer-related pulmonary embolism: Data from a multicenter cohort study

Value of computed tomography pulmonary angiography measurements in predicting 30-day mortality among patients with acute pulmonary embolism

Purpose

Late diagnosis is associated with high mortality rates in acute pulmonary embolism (PE), so early diagnosis and risk assessment are crucial. We aim to evaluate computed tomography pulmonary angiography measurements to identify relationships with 30-day mortality in patients with pulmonary embolism. This study investigated the utility of computed tomography pulmonary angiography (CTPA) measures in determining 30-day PE-related mortality and identified various echocardiographic, demographic, and clinical variables that were independently associated with short-term mortality in patients with acute PE.

Material and methods

This retrospective study examined data from July 2018 to April 2023. A total of 118 patients were included in the study. Clinical and demographic characteristics, laboratory findings, echocardiographic data, and CTPA images were retrieved from the electronic database and patient charts.

Results

The rate of 30-day mortality was 14.41%. Deceased patients were significantly older than survivors (73.53 ± 14.17 vs. 60.23 ± 17.49 years; p = 0.004), but the sex distribution was similar. In multivariable logistic regression, having received radiotherapy for malignancy, high pulmonary artery obstruction index % (> 46.2), high left pulmonary artery diameter (> 23.9 mm), and high coronary artery calcification score (> 5.5) were independently associated with mortality.

Conclusions

These results reveal specific parameters that can assist acute PE management by enabling the identification of critical events. Despite promising results in predicting short-term mortality in acute PE, further prospective cohort studies are needed to confirm the results of the present study.

RV size may predict death in unstable patients with PE

BACKGROUND

Pulmonary emboli (PE) is a life threatening condition that discovered in many patients only "post mortem". Sub massive and massive PE that led to hemodynamic collapse characterized by right ventricular (RV) dysfunction, leading to a higher risk of death.

OBJECTIVES

To assess the ability to predict in hospital death of patients with acute PE, using a non-gated computed tomography pulmonary angiography (CTPA), based on the dimensions of the right ventricle.

METHODS

A retrospective study that analyzed CTPA images of patients admitted with acute PE during the years 2012-2017. The cohort study included 300 patients with documented acute PE, among them 255 hospitalized in medical (non-intensive care unit) wards, 45 were hospitalized in an intensive care unit (ICU).

RESULTS

Among the 45 patients admitted to the ICU 8% died. Larger RV diameters predicted mortality (OR = 10.14, 95% CI [1.09-93.86]) as well as lower systolic and diastolic blood pressure measurements (p = 0.001 and 0.01). Among the 255 patients admitted to the Internal Medicine Ward 7% died. Older age (p = 0.028), sepsis and cancer (both p < 0.001), high WBCs count (p < 0.001), and renal failure (p < 0.001) predicted death. Lower blood pressure (systolic and diastolic) (p < 0.001, 0.008), older age (p < 0.007), sepsis (p < 0.001), cancer (p = 0.006), higher WBCs count (p < 0.001), and impaired renal function (p < 0.001) predicted death in patients admitted with acute PE.

CONCLUSIONS

Clinical parameters and hematological parameters could predict death of patients admitted with acute PE. RV diameter, measured by the non-ECG gated CTPA, had an additive predictive value for patients who admitted to the ICU.

Do antiangiogenics promote clot instability? Data from the TESEO prospective registry and Caravaggio clinical trial

Background  Venous thromboembolism (VTE) is a common complication in cancer patients. Much of its morbidity stems from the development of fatal pulmonary embolisms (PE). Little is known about the factors involved in clot stability, with angiogenesis possibly being implicated.

Methods  The database is from the TESEO prospective registry that recruits cancer patients with VTE from 41 Spanish hospitals. Independent validation was conducted in a cohort from the Caravaggio trial. The objective is to evaluate the association between exposure to antiangiogenic therapies and the PE/VTE proportion in oncological patients.

Results  In total, 1,536 subjects were evaluated; 58.4% ( n  = 894) had a PE and 7% ( n  = 108) received antiangiogenic therapy (bevacizumab in 75%). The PE/VTE proportion among antiangiogenic-treated individuals was 77/108 (71.3%) versus 817/1,428 (57.2%) among those receiving other alternative therapies ( p  = 0.004). The effect of the antiangiogenics on the PE/VTE proportion held up across all subgroups except for active smokers or those with chronic obstructive pulmonary disease. Exposure to antiangiogenics was associated with increased PEs, odds ratio (OR) 2.27 (95% CI, 1.42–3.63). In the Caravaggio trial, PE was present in 67% of the individuals treated with antiangiogenics, 50% of those who received chemotherapy without antiangiogenic treatment, and 60% without active therapy ( p  = 0.0016).

Conclusion  Antiangiogenics are associated with increased proportion of PE in oncological patients with VTE. If an effect on clot stability is confirmed, the concept of thrombotic risk in cancer patients should be reconsidered in qualitative terms.

Prognostic value of CT pulmonary angiography parameters in acute pulmonary embolism

OBJECTIVES

Computed tomographic pulmonary angiography (CTPA) is the first-line test in acute pulmonary embolism (APE) diagnostic algorithm, but its correlation with short-term outcome remains not clear at all. The aim is to determine whether CTPA findings can predict 30-day mortality of patients with APE in Emergency Department.

METHODS

This retrospective monocentric study involved 780 patients with APE diagnosed at the Emergency Department of our institution (period 2010-2019). These CTPA findings were evaluated: embolic obstruction burden score (Qanadli score), common pulmonary artery trunk diameter, right-to-left ventricular ratio, azygos vein and coronary sinus diameters. Comorbidities and fatal/nonfatal adverse outcomes within 30 days were recorded. Troponin I values were correlated with angiographic parameters with multiple logistic regression analysis.

RESULTS

The all-cause and APE-related 30-day mortality rates were 5.9% and 3.6%, respectively. Patients who died within 30 days were older with higher prevalence rates of malignancy. Qanadli score and all CTPA parameters correlate with Troponin I level and the presence of RVD at echocardiography (p values < 0.0001). Instead, RV/LV ratio and coronary sinus diameter correlate with 30-day mortality (p values < 0.05). At the multivariate logistic regression analysis, only coronary sinus and RVD remained significant with an HR = 2.5 (95% CI 1.1-5.6) and HR = 1.9 (95% CI 0.95-3.7), respectively.

CONCLUSION

CTPA quantification of right ventricular strain is an accurate predictor of 30-day mortality. In particular, it seems that a dilated coronary sinus (>9 mm) has an additional prognostic value in association with echocardiographic signs of right-heart disfunction and high Troponin I levels.

A snapshot of cancer-associated thromboembolic disease in 2018-2019: First data from the TESEO prospective registry

BACKGROUND

The ever-growing complexity of cancer-associated thrombosis (CAT), with new antineoplastic drugs and anticoagulants, distinctive characteristics, and decisions with low levels of evidence, justifies this registry.

METHOD

TESEO is a prospective registry promoted by the Spanish Society of Medical Oncology to which 34 centers contribute cases. It seeks to provide an epidemiological description of CAT in Spain.

RESULTS

Participants (N=939) with CAT diagnosed between July 2018 and December 2019 were recruited. Most subjects had advanced colon (21.4%), non-small cell lung (19.2%), and breast (11.1%) cancers, treated with dual-agent chemotherapy (28.4%), monochemotherapy (14.4%), or immune checkpoint inhibitors (3.6%). Half (51%) were unsuspected events, albeit only 57.1% were truly asymptomatic. Pulmonary embolism (PE) was recorded in 571 (58.3%); in 120/571 (21.0%), there was a concurrent deep venous thromboembolism (VTE). Most initially received low molecular weight heparin (89.7%). Suspected and unsuspected VTE had an OS rate of 9.9 (95% CI, 7.3-non-computable) and 14.4 months (95% CI, 12.6-non-computable) (p=0.00038). Six-month survival was 80.9%, 55.9%, and 55.5% for unsuspected PE, unsuspected PE admitted for another reason, and suspected PE, respectively (p<0.0001). The 12-month cumulative incidence of venous rethrombosis was 7.1% (95% CI, 4.7-10.2) in stage IV vs 3.0% (95% CI, 0.9-7.1) in stages I-III. The 12-month cumulative incidence of major/clinically relevant bleeding was 9.6% (95% CI, 6.1-14.0) in the presence of risk factors.

CONCLUSION

CAT continues to be a relevant problem in the era of immunotherapy and targeted therapies. The initial TESEO data highlight the evolution of CAT, with new agents and thrombotic risk factors.

Risk stratification of acute pulmonary embolism based on the clot volume and right ventricular dysfunction on CT pulmonary angiography

OBJECTIVE

To test the feasibility of the clot volume and right ventricular dysfunction for risk stratification of acute pulmonary embolism (APE) patients.

METHODS

CT pulmonary angiography (CTPA) images of 158 APE patients were collected. After excluding 38 (24.1%) patients due to unsatisfactory quality, 120 APE patients (61 males and 59 females) were divided into high-risk (n = 37) and non-high-risk (n = 83) groups. Clot burden was measured by an automated programme (clot volume) and by two semi-quantitative systems (Qanadli and Mastora scores). The ratios of the right ventricular diameter to left ventricular diameter (RVd/LVd) and area (RVa/LVa) were obtained. The correlations amongst the above parameters were analysed. Receiver operating characteristic (ROC) curves were calculated to determine the efficacy of high-risk APE. Multivariate analyses were used to identify the independent predictors.

RESULTS

Strong positive correlations were found between the clot volume and both Qanadli score (r²  = 0.696, P < 0.001) and Mastora score (r²  = 0.728, P < 0.001), and moderate correlations were found between the clot volume and both RVd/LVd (r²  = 0.392, P < 0.001) and RVa/LVa (r²  = 0.389, P < 0.001). The clot volume contributed the highest efficacy (AUC = 0.992) for the identification of high-risk cases, followed by Mastora score (0.968), Qanadli score (0.952), RVa/LVa (0.900) and RVd/LVd (0.892). The clot volume and RVd/LVd were two independent factors of high-risk APE.

CONCLUSIONS

The clot volume is correlated with semi-quantitative clot burden scores and CT measured cardiac parameters. The clot volume and RVd/LVd were two independent factors of high-risk APE patients.

Health risk stratification based on computed tomography pulmonary artery obstruction index for acute pulmonary embolism

Early effective identification of high-risk patients for acute pulmonary embolism (APE) contributes to timely treatment. The pulmonary artery obstruction index (PAOI) in computed tomography angiography (CTA) is a semi-quantitative observation index, commonly used to evaluate the severity of a patient's condition. This study explores the ability of PAOI to assess the risk stratification of APE. Thirty patients with APE were analysed. They were classified according to the guidelines, and the PAOI and cardiovascular parameters were measured in CTA. The difference of PAOI between different risk stratification patients was compared, and the predictive value of the PAOI for high-risk stratification was evaluated by the receiver operating characteristic curve. The correlation between PAOI and cardiovascular parameters was also analysed by Spearman correlation analysis. The PAOI in low- and high-risk patients was (33.2 ± 18.6)% and (68.1 ± 11.8)% respectively, and the difference was statistically significant. The PAOI was strongly predictive for high-risk patients. The cut-off value was 52.5%, with a sensitivity of 100% and specificity of 81.0%. The PAOI was correlated with the main cardiovascular parameters. We conclude that the PAOI in CTA is helpful for assessing risk stratification in patients with APE, which contributes to the selection of both the treatment plan and prognostic evaluation.

Predicting serious complications in patients with cancer and pulmonary embolism using decision tree modelling: the EPIPHANY Index

Background:

Our objective was to develop a prognostic stratification tool that enables patients with cancer and pulmonary embolism (PE), whether incidental or symptomatic, to be classified according to the risk of serious complications within 15 days.

Methods:

The sample comprised cases from a national registry of pulmonary thromboembolism in patients with cancer (1075 patients from 14 Spanish centres). Diagnosis was incidental in 53.5% of the events in this registry. The Exhaustive CHAID analysis was applied with 10-fold cross-validation to predict development of serious complications following PE diagnosis.

Results:

About 208 patients (19.3%, 95% confidence interval (CI), 17.1–21.8%) developed a serious complication after PE diagnosis. The 15-day mortality rate was 10.1%, (95% CI, 8.4–12.1%). The decision tree detected six explanatory covariates: Hestia-like clinical decision rule (any risk criterion present vs none), Eastern Cooperative Group performance scale (ECOG-PS; <2 vs ⩾2), O₂ saturation (<90 vs ⩾90%), presence of PE-specific symptoms, tumour response (progression, unknown, or not evaluated vs others), and primary tumour resection. Three risk classes were created (low, intermediate, and high risk). The risk of serious complications within 15 days increases according to the group: 1.6, 9.4, 30.6% P<0.0001. Fifteen-day mortality rates also rise progressively in low-, intermediate-, and high-risk patients: 0.3, 6.1, and 17.1% P<0.0001. The cross-validated risk estimate is 0.191 (s.e.=0.012). The optimism-corrected area under the receiver operating characteristic curve is 0.779 (95% CI, 0.717–0.840).

Conclusions:

We have developed and internally validated a prognostic index to predict serious complications with the potential to impact decision-making in patients with cancer and PE.