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Ruiz-Llobet A, Gassiot S, Sarrate E, Zubicaray J, Rives S, Suleman W, Berrueco R. Thrombin Generation Profile Using ST-Genesia after PEG-asparaginase in Pediatric Patients with Acute Lymphoblastic Leukemia. Thromb Haemost 2024. [PMID: 38684189 DOI: 10.1055/a-2316-4547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Venous thromboembolism (VTE) etiology in children with acute lymphoblastic leukemia (ALL) is multifactorial. The use of global assays of hemostasis as a thrombin generation test (TGT) is useful to individualize VTE risk in adult patients. This prospective cohort study aimed to evaluate the usefulness of an automated TGT to evaluate VTE risk during ALL treatment in children. METHODS TGT (automated analyzer ST Genesia; ThromboScreen) and pro- and anticoagulant plasma proteins were analyzed during ALL treatment in pediatric patients following LAL-SEHOP-PETHEMA-2013 guidelines. Results were compared with a series of pediatric normal controls and evaluated according to pegylated asparaginase PEG-ASP administration and to VTE risk factors. RESULTS The study included 67 patients: males n = 35, B-ALL (n = 60). None had a VTE during the evaluated period. Compared to healthy controls, the normalized endogenous thrombin potential (N-ETP) ratio in patients was higher and ETP inhibition (ETP-inh) was lower, especially after PEG-ASP administration. Plasmatic protein C and protein S levels decreased after PEG-ASP administration, but antithrombin mean level did not. A bivariant analysis showed that ETP-inh was lower in patients >10 years old (p = 0.05) and in those with non-O blood type (p = 0.005). A linear mixed model also showed a higher TGT prothrombotic profile in patients with inherited thrombophilia. CONCLUSION TGT could be a biomarker of a high VTE risk in ALL pediatric patients. Non-O blood group and inherited thrombophilia were associated with a significantly higher thrombotic profile, and an increased profile was also observed after administration of PEG-ASP.
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Affiliation(s)
- Anna Ruiz-Llobet
- Pediatric Hematology Department, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
| | - Susanna Gassiot
- Laboratory of Hematology, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Universitat de Barcelona, Barcelona, Spain
| | - Edurne Sarrate
- Laboratory of Hematology, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Universitat de Barcelona, Barcelona, Spain
| | - Josune Zubicaray
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Susana Rives
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
- Hematology and Oncology, Leukemia and Lymphoma Department, Pediatric Cancer Center Barcelona, Hospital Sant Joan de Déu de Barcelona, Esplugues de Llobregat, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Barcelona, Spain
| | - Warda Suleman
- Laboratory of Hematology, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Universitat de Barcelona, Barcelona, Spain
| | - Rubén Berrueco
- Pediatric Hematology Department, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Esplugues de Llobregat, Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
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O'Brien SH, Rodriguez V, Lew G, Newburger JW, Schultz CL, Orgel E, Derr K, Ranalli MA, Esbenshade AJ, Hochberg J, Kang HJ, Dinikina Y, Mills D, Donovan M, Dyme JL, Favatella NA, Mitchell LG. Apixaban versus no anticoagulation for the prevention of venous thromboembolism in children with newly diagnosed acute lymphoblastic leukaemia or lymphoma (PREVAPIX-ALL): a phase 3, open-label, randomised, controlled trial. Lancet Haematol 2024; 11:e27-e37. [PMID: 37980924 DOI: 10.1016/s2352-3026(23)00314-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Paediatric patients with acute lymphoblastic leukaemia or lymphoma are at increased risk of venous thromboembolism resulting in increased mortality and morbidity. We hypothesised that apixaban, a direct oral anticoagulant, would safely reduce venous thromboembolism in this patient population. METHODS PREVAPIX-ALL was a phase 3, open-label, randomised, controlled trial conducted in 74 paediatric hospitals in 9 countries. Participants aged 1 year or older to younger than 18 years with newly diagnosed acute lymphoblastic leukaemia (pre-B cell or T cell) or lymphoblastic lymphoma (B cell or T cell immunophenotype) and a central venous line in place throughout induction were randomly assigned 1:1 to standard of care (SOC, ie, no systemic anticoagulation) or weight-adjusted twice-daily apixaban during induction. Randomisation was performed centrally and stratified by age (those <10 years or those ≥10 years). Participants weighing 35 kg or less were administered 2·5 mg twice daily of apixaban as a 2·5 mg tablet, 0·5 mg tablets, or 0·4 mg/mL oral solution, while those weighing more than 35 kg were administered weight-adjusted prophylactic doses using 0·5 mg tablets or the 0·4 mg/mL oral solution twice daily. Primary outcomes were assessed by a blinded central adjudication committee. The primary efficacy outcome for the intention to treat population was the composite of symptomatic or clinically unsuspected venous thromboembolism, the primary safety outcome was major bleeding, and secondary safety outcomes included clinically relevant non-major (CRNM) bleeding. Patients were screened for venous thromboembolism by ultrasound and echocardiogram at the end of induction. The trial was registered with ClinicalTrials.gov (NCT02369653) and is now complete. FINDINGS Between Oct 22, 2015, and June 4, 2021, 512 participants were randomly assigned and included in analyses (222 [43%] female and 290 [57%] male; 388 [76%] White, 52 [10%] Asian, 24 [5%] Black or African American, and 48 [9%] other races; and 122 [24%] Hispanic or Latino ethnicity). During a median follow-up period of 27 days (IQR 26-28), 31 (12%) of 256 patients on apixaban had a composite venous thromboembolism compared with 45 (18%) of 256 participants receiving SOC (relative risk [RR] 0·69, 95% CI 0·45-1·05; p=0·080). Two major bleeding events occurred in each group (RR 1·0, 95% CI 0·14-7·01; p=1·0). A higher incidence of CRNM bleeding, primarily grade 1 or 2 epistaxis, occurred in the apixaban group (11 [4%] of 256 participants) compared with the SOC group (3 [1%] of 256; RR 3·67, 95% CI 1·04-12·97, p=0·030). The most frequent grade 3-5 adverse events in both groups were thrombocytopenia (n=28 for the apixaban group and n=20 for the SOC group) or platelet count decreased (n=49 and n=45), anaemia (n=77 and n=74), febrile neutropenia (n=27 and n=20), and neutropenia (n=16 and n=17) or neutrophil count decreased (n=22 and n=25). Five deaths occurred, which were due to infection (n=3 in the SOC group), cardiac arrest (n=1 in apixaban group), and haemorrhagic cerebral sinus vein thrombosis (n=1 in the SOC group). There was one apixaban-related death (coagulopathy and haemorrhage after cardiac arrest of unknown cause). INTERPRETATION PREVAPIX-ALL is, to our knowledge, the first trial assessing primary thromboprophylaxis using a direct oral anticoagulant in paediatric patients with acute lymphoblastic leukaemia or lymphoma. No statistically significant treatment benefit was identified in participants receiving apixaban. Major and CRNM bleeding were infrequent overall, but a higher incidence of CRNM bleeding (primarily epistaxis in younger children) occurred in participants receiving apixaban. For patients deemed to be at particularly high risk of thrombosis, PREVAPIX-ALL provides encouraging safety data for the use of apixaban in clinical settings in which the potential benefits are thought to outweigh the risk of bleeding. FUNDING Bristol Myers Squibb-Pfizer Alliance.
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology and Oncology, Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University, Columbus, OH, USA.
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology and Oncology, Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University, Columbus, OH, USA
| | - Glen Lew
- Bristol Myers Squibb, Lawrenceville, NJ, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Corinna L Schultz
- Nemours Center for Cancer and Blood Disorders, Nemours Children's Health, Wilmington, DE, USA
| | - Etan Orgel
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kimberly Derr
- Department of Pediatric Oncology, Geisinger, Danville, PA, USA
| | - Mark A Ranalli
- Division of Pediatric Hematology and Oncology, Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University, Columbus, OH, USA
| | - Adam J Esbenshade
- Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jessica Hochberg
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Cancer Research Institute, Wide River Institute of Immunology, Seoul National University Children's Hospital, Seoul, South Korea
| | - Yulia Dinikina
- Department of Chemotherapy for Oncohematological Diseases and Bone Marrow Transplantation for Children, Almazov National Medical Research Centre, Saint Petersburg, Russian
| | - Donna Mills
- Bristol Myers Squibb, Lawrenceville, NJ, USA
| | | | | | | | - Lesley G Mitchell
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Ni J, Chen M, Su Y, Gao Q, Liu L, Lu X. Right femoral vein and right dorsal artery thrombosis in childhood acute myeloid leukemia: A case report. Medicine (Baltimore) 2023; 102:e35121. [PMID: 37832057 PMCID: PMC10578772 DOI: 10.1097/md.0000000000035121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/17/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND It is rare for newly diagnosed (de novo) or newly treated acute myeloid leukemia (AML) complicated with thrombotic complications, especially combined arterial and venous thrombosis. METHODS We reported a 13-year-old boy diagnosed with AML and leukocytosis, who developed right femoral vein and right dorsal artery thrombosis during chemotherapy. After treatment with low molecular weight heparin, diosmin, and alprostadil, symptoms were relieved. Unfortunately, the child suffered from coagulopathy afterward, which was unexpectedly caused by vitamin K deficiency. RESULTS After supplementation with vitamin K and prothrombin complex concentrate, coagulation function recovered. CONCLUSION For childhood AML patients with high thrombotic risks, close monitoring during anticoagulant treatment was necessary. Concomitantly, we should be alert to past medication history and combined medication use, especially those that may lead to vitamin K deficiency, secondary bleeding, and coagulation disorders. Rational use of antibiotics, anticoagulants, and antitumor drugs must be guaranteed.
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Affiliation(s)
- Jiaqi Ni
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Min Chen
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yali Su
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatric Hematology and Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Qianqian Gao
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Ultrasound, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lingjun Liu
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiaoxi Lu
- Key Laboratory of Birth Defects & Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Department of Pediatric Hematology and Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
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Yin M, Wang H, Guan X, Gao J, Yang M, Wang N, Liu T, Tang J, Leung AWK, Zhou F, Wu X, Huang J, Li H, Hu S, Tian X, Jiang H, Cai J, Zhai X, Shen S, Hu Q. Venous thromboembolism in children with acute lymphoblastic leukemia in China: a report from the Chinese Children's Cancer Group-ALL-2015. Front Med 2023; 17:518-526. [PMID: 36807106 DOI: 10.1007/s11684-022-0958-6] [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: 04/05/2022] [Accepted: 08/18/2022] [Indexed: 02/21/2023]
Abstract
Venous thromboembolism (VTE) is a complication in children with acute lymphoblastic leukemia (ALL). The Chinese Children's Cancer Group-ALL-2015 protocol was carried out in China, and epidemiology, clinical characteristics, and risk factors associated with VTE were analyzed. We collected data on VTE in a multi-institutional clinical study of 7640 patients with ALL diagnosed in 20 hospitals from January 2015 to December 2019. First, VTE occurred in 159 (2.08%) patients, including 90 (56.6%) during induction therapy and 108 (67.92%) in the upper extremities. T-ALL had a 1.74-fold increased risk of VTE (95% CI 1.08-2.8, P = 0.022). Septicemia, as an adverse event of ALL treatment, can significantly promote the occurrence of VTE (P < 0.001). Catheter-related thrombosis (CRT) accounted for 75.47% (n = 120); and, symptomatic VTE, 58.49% (n = 93), which was more common in patients aged 12-18 years (P = 0.023), non-CRT patients (P < 0.001), or patients with cerebral thrombosis (P < 0.001). Of the patients with VTE treated with anticoagulation therapy (n = 147), 4.08% (n = 6) had bleeding. The VTE recurrence rate was 5.03% (n = 8). Patients with VTE treated by non-ultrasound-guided venous cannulation (P = 0.02), with residual thrombus (P = 0.006), or with short anticoagulation period (P = 0.026) had high recurrence rates. Thus, preventing repeated venous puncture and appropriately prolonged anticoagulation time can reduce the risk of VTE recurrence.
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Affiliation(s)
- Mengmeng Yin
- Department of Pediatrics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hongsheng Wang
- Department of Hematology/Oncology, Children's Hospital of Fudan University, Shanghai, 201100, China
| | - Xianmin Guan
- Department of Hematology/Oncology, Chongqing Medical University Affiliated Children's Hospital, Chongqing, 400015, China
| | - Ju Gao
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Disease of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, 610041, China
| | - Minghua Yang
- Department of Pediatrics, Xiangya Hospital Central South University, Changsha, 410008, China
| | - Ningling Wang
- Department of Pediatrics, Anhui Medical University Second Affiliated Hospital, Hefei, 230601, China
| | - Tianfeng Liu
- State Key Laboratory of Experimental Hematology and Division of Pediatric Blood Diseases Center, Institute of Hematology and Blood Diseases Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Tianjin, 300020, China
| | - Jingyan Tang
- Department of Hematology/Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, Shanghai, 200120, China
| | - Alex W K Leung
- Department of Pediatrics, Hong Kong Children's Hospital, The Chinese University of Hong Kong, Hong Kong SAR, 999077, China
| | - Fen Zhou
- Department of Pediatrics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xuedong Wu
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, 516006, China
| | - Jie Huang
- Department of Hematology/Oncology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Hong Li
- Department of Hematology/Oncology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, 200062, China
| | - Shaoyan Hu
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, 215002, China
| | - Xin Tian
- Department of Hematology/Oncology, Kunming Children's Hospital, Kunming, 650103, China
| | - Hua Jiang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, 510620, China
| | - Jiaoyang Cai
- Department of Hematology/Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, Shanghai, 200120, China
| | - Xiaowen Zhai
- Department of Hematology/Oncology, Children's Hospital of Fudan University, Shanghai, 201100, China.
| | - Shuhong Shen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, Shanghai, 200120, China.
| | - Qun Hu
- Department of Pediatrics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Højfeldt SG, Grell K, Hvitfeldt L, Wehner PS, Bjerre J, Albertsen BK. Correlation between asparaginase enzyme activity levels and coagulation parameters during childhood acute lymphoblastic leukemia treatment. Pediatr Blood Cancer 2023; 70:e30085. [PMID: 36377699 DOI: 10.1002/pbc.30085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/30/2022] [Accepted: 10/05/2022] [Indexed: 11/16/2022]
Abstract
Thromboembolism is a serious toxicity in the treatment of acute lymphoblastic leukemia (ALL), but little is known about the correlation between asparaginase enzyme activity (ASA) levels and coagulation parameters. We included 65 non-high risk ALL patients, aged 1-17 years. Coagulation parameters and corresponding ASA levels were measured during asparaginase treatment. We found ASA to be negatively correlated with antithrombin and fibrinogen up to ASA levels of 250 IU/L, after which these parameters reached a plateau and did not decrease further with further increase of ASA. Patients with silent inactivation of asparaginase had normal coagulation parameters.
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Affiliation(s)
- Sofie Gottschalk Højfeldt
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kathrine Grell
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Pediatrics and Adolescent Medicine, University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lone Hvitfeldt
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peder Skov Wehner
- Department of Pediatric Hematology and Oncology, H. C. Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Jesper Bjerre
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Birgitte Klug Albertsen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Falanga A, Brenner B, Khorana AA, Francis C. Thrombotic complications in patients with cancer: Advances in pathogenesis, prevention, and treatment—A report from ICTHIC 2021. Res Pract Thromb Haemost 2022; 6:e12744. [PMID: 35794962 PMCID: PMC9248072 DOI: 10.1002/rth2.12744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/28/2022] [Accepted: 05/03/2022] [Indexed: 11/05/2022] Open
Abstract
Venous thromboembolism (VTE) is a common complication in cancer patients, resulting in deep vein thrombosis (DVT) or pulmonary embolism (PE), and is responsible for high morbidity and mortality. This article discusses evidence and future perspectives on pathogenesis and prevention and treatment of thrombotic complications in patients with cancer. In April 2021, international basic researchers and clinicians met for the virtual edition of the 10th International Conference on Thrombosis & Hemostasis Issues in Cancer. Pathogenic mechanisms, markers and scores for risk assessment, diagnosis and therapy issues, current prophylaxis recommendations, and special settings, such as palliative care, pediatrics, and COVID‐19 patients were discussed. Emerging areas of interest in cancer associated VTE are the role of immunotherapy, platelet activation markers, genetic alterations and real‐world systems‐based approaches to prevention and treatment.
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Affiliation(s)
- Anna Falanga
- Division of Immunohematology and Transfusion Medicine Hospital Papa Giovanni XXIII Bergamo Italy
- Department of Medicine and Surgery University of Milan Bicocca Milan Italy
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation Rambam Health Care Campus Haifa Israel
| | - Alok A. Khorana
- Taussig Cancer Institute Cleveland Clinic Lerner College of Medicine Cleveland Clinic Cleveland Ohio USA
| | - Charles W. Francis
- James P Wilmot Cancer Center and University of Rochester Rochester NY USA
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Cancer associated thrombosis in pediatric patients. Best Pract Res Clin Haematol 2022; 35:101352. [DOI: 10.1016/j.beha.2022.101352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022]
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8
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Ruiz-Llobet A, Gassiot S, Sarrate E, Zubicaray J, Dapena JL, Rives S, Sevilla J, Menárguez López Á, Panesso Romero M, Montoya C, Vagace JM, Molina Hurtado JR, García-Morín M, García Abós M, Mendoza Sánchez MC, Lendínez F, Palomo Moraleda P, Tallón M, González B, Urrutia E, Serna JV, Peláez Pleguezuelos I, Martínez Merino M, Ramos Elbal E, Orellana E, Benítez Muñoz H, Berrueco R. Venous thromboembolism in pediatric patients with acute lymphoblastic leukemia under chemotherapy treatment. Risk factors and usefulness of thromboprophylaxis. Results of LAL-SEHOP-PETHEMA-2013. J Thromb Haemost 2022; 20:1390-1399. [PMID: 35289066 DOI: 10.1111/jth.15699] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Symptomatic venous thromboembolism (VTE) is diagnosed in 3%-14% of patients during pediatric acute lymphoblastic leukemia (ALL) therapy. There are well-known risk factors, but the role of others as inherited thrombophilia is still controversial. Prophylaxis with low molecular weight heparin (LMWH) has been described, but its use is not globally accepted. METHODS A retrospective multicentric study in ALL patients 1-18 years old following SEHOP-PETHEMA-2013 treatment guideline was performed to evaluate VTE rate, anticoagulant treatment, outcome, risk factors, and safety and usefulness of LMWH administration as primary thromboprophylaxis in children with inherited thrombophilia. RESULTS A total of 652 patients were included in the study. VTE incidence was 8.7%. Most of the cases occurred during induction therapy associated with central venous catheter. Univariant analysis showed that family history of thrombosis, presence of mediastinal mass, high-risk treatment group, and inherited thrombophilia were statistically significant risk factors. LMWH administration seemed to decrease VTE rate in patients with inherited thrombophilia and those with T-cell ALL phenotype. CONCLUSION Most of the VTE cases occurred in patients without inherited thrombophilia, but when it is present, the VTE risk is higher. LMWH administration was useful to decrease VTE in these patients.
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Affiliation(s)
- Anna Ruiz-Llobet
- Servicio de Hematología Pediátrica, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, España
| | - Susanna Gassiot
- Laboratorio de Hematología, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
| | - Edurne Sarrate
- Laboratorio de Hematología, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
| | - Josune Zubicaray
- Servicio de Hematología y Hemoterapia, Hematología y Oncología Pediátricas, Hospital Infantil Universitario Niño Jesús, Fundación para la Investigación Biomédica del Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - José Luis Dapena
- Servicio de Hematología Pediátrica, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, España
| | - Susana Rives
- Servicio de Hematología Pediátrica, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, España
| | - Julián Sevilla
- Laboratorio de Hematología, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
| | - Ángela Menárguez López
- Servicio Oncología y Hematología Pediátricas, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Melissa Panesso Romero
- Servicio Oncología y Hematología Pediátricas, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Catalina Montoya
- Departamento de Pediatría, Hospital General Universitario de Alicante, Alicante, Spain
| | - José Manuel Vagace
- Servicio de Hematología y Hemoterapia, Complejo Hospitalario Universitario de Badajoz, Departamento de Ciencias Biométicas Universidad de Extremadura, Badajoz, Spain
| | | | - Marina García-Morín
- Sección de Hematología y Oncología Pediátricas, Hospital General Universitario Gregorio Marañón, Madrid, España
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, España
| | - Miriam García Abós
- Servicio de Oncología Pediátrica, Hospital Universitario Donostia, San Sebastian, Spain
| | | | - Francisco Lendínez
- Servicio de Pediatría, Complejo Hospitalario de Torrecárdenas, Almería, Spain
| | - Pilar Palomo Moraleda
- Unidad de Hematología Pediátrica, Servicio de Hematología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - María Tallón
- Servicio de Pediatría, Hospital Álvaro Cunquerio Vigo, Vigo, Spain
| | - Berta González
- Servicio de Hematología y Oncología Pediátricas, Hospital Universitario La Paz, Valencia, Spain
| | - Emilia Urrutia
- Servicio de Pediatría y Oncohematología Pediátricas, Hospital Materno Infantil Virgen de las Nieves, Granada, Spain
| | - José Vicente Serna
- Unidad Oncología y Hematología y TPH, Servicio de Pediatría, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Marta Martínez Merino
- Unidad de Oncohematología Pediátrica, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Eduardo Ramos Elbal
- Sección de Oncohematología Pediátrica, Hospital Clínico Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain
| | - Elena Orellana
- Servicio de Hematología y Oncología Pediátricas, Hospital 12 de Octubre, Madrid, Spain
| | - Helga Benítez Muñoz
- Servicio de Oncología Pediátrica, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Rubén Berrueco
- Servicio de Hematología Pediátrica, Hospital Sant Joan de Déu Barcelona, Institut de Recerca Pediàtrica, Hospital San Joan de Déu de Barcelona (IRP-HSJD), Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, España
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9
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Carmona R, Kizilocak H, Marquez-Casas E, Vasquez S, Ji L, Ko RH, Young G, Jaffray J. Markers of hypercoagulability in children with newly diagnosed acute lymphoblastic leukemia. Pediatr Blood Cancer 2022; 69:e29522. [PMID: 34963026 DOI: 10.1002/pbc.29522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 10/13/2021] [Accepted: 11/23/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a known complication for children with acute lymphoblastic leukemia (ALL). The aim of this study was to identify laboratory biomarkers that predict which children with ALL are at risk for VTE during induction chemotherapy. MATERIALS AND METHODS Newly diagnosed ALL patients admitted to Children's Hospital Los Angeles with a central venous catheter (CVC) were eligible to participate. Participants' blood samples (complete blood count [CBC], quantitative D-dimer, prothrombin fragment 1.2 [PTF 1.2], and thrombin-antithrombin complexes [TAT]) were collected at day 0 (baseline/prior to induction), day 7 (±2 days), day 14 (±2 days), day 21 (±2 days), and day 28 (±2 days) of induction chemotherapy or until participants presented with a symptomatic VTE. RESULTS Seventy-five participants aged 1-21 years were enrolled and included in the final analysis. Twenty-six (35%) of the 75 participants were diagnosed with a CVC-associated VTE (22 asymptomatic and four symptomatic). There was a statistically significant difference between VTE and non-VTE participants for D-dimer (odds ratio [OR] 1.61, 95% confidence interval [CI]: 1.59-1.64), TAT (OR 1.34, 95% CI: 1.32-1.38), and PTF 1.2 (OR 1.31, 95% CI: 1.25-1.37) at all time points. Participants >10 years had a significantly higher risk of developing a VTE compared to participants <4 years (p = .007). CONCLUSION Older children with ALL as well as those with an elevated TAT, PTF 1.2, or D-dimer showed an increased risk of VTE, which may hold potential for predicting VTE in future studies.
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Affiliation(s)
- Roxana Carmona
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Hande Kizilocak
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Elizabeth Marquez-Casas
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Siobhan Vasquez
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Lingyun Ji
- Division of Biostatistics, Department of Preventive Medicine, University of Southern California, Los Angeles, California, USA
| | - Richard H Ko
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Julie Jaffray
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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10
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Zadeh C, AlArab N, Muwakkit S, Atweh LA, Tamim H, Makki M, Salhab HA, Hourani R. Stroke in Middle Eastern children with cancer: prevalence and risk factors. BMC Neurol 2022; 22:31. [PMID: 35042459 PMCID: PMC8764852 DOI: 10.1186/s12883-022-02556-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
To determine the prevalence and to characterize the different types of strokes in children with cancer at the Children’s Cancer Center of Lebanon (CCCL), in addition to assess the factors and clinical findings leading to stroke in children.
Methods
We retrospectively reviewed the medical records and brain images (MRIs and CTs) of children admitted to the CCCL and diagnosed with cancer between years 2008 and 2017. Brain images were reviewed for the strokes’ onset, size, location, possible origin, its recurrence and type: intracranial hemorrhage (ICH), acute arterial ischemic stroke, and cerebral sinus venous thrombosis (CSVT) with and without venous infarct. Medical charts of the patients were reviewed for age, sex, their type of cancer, the treatment protocol they followed, and abnormal findings on their laboratory studies and neurological exams.
Results
Out of the 905 charts reviewed, twenty-seven children with variable types of cancer had strokes, with a prevalence of 2.9%. Their median age at cancer diagnosis was 9.4 (4.8-13.7) years and the median age at stroke onset was 10.6 (6.7-15.5) years. The median time between the cancer diagnosis and the stroke episode was 6 months. CSVT cases were the most common (60%) followed by acute arterial ischemic (22%) and hemorrhagic strokes (18%), with CSVT being the latest to occur. We observed that the different types of strokes were related to some types of cancer. Of the children that had acute arterial ischemic stroke in this cohort, 83% had brain tumors, of the children who had CSVT, 87.5% had leukemia, and of the children who had hemorrhagic stroke, 40% had leukemia. Neurological abnormalities were more prevalent in acute arterial ischemic stroke (80%). Patients with CSVT recovered better than those with other types of strokes. Strokes recurred in 60% of ischemic strokes. L-Asparaginase was significantly associated with CSVT.
Conclusions
The prevalence of strokes was 2.9% in children with cancer. We were able to identify factors related to the types of the stroke that occurred in children including the type and location of the cancer the type of treatment received, and stroke recurrence.
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11
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Hashem H, Zeineddin M, Bater R, Amayiri N, Al-Qasem W, Hammo B, Sultan I, AlMasri R, Abdel-Razeq H. Thrombosis and Anticoagulant Therapy Among Pediatric Cancer Patients: Real-Life Data. Cureus 2021; 13:e20084. [PMID: 34987942 PMCID: PMC8719720 DOI: 10.7759/cureus.20084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Venous thromboembolism (VTE) in children is relatively rare, and more so among those with cancer. In this study, we report the characteristics and outcomes of children with cancer-associated thrombosis. Methods: We reviewed institutional databases for all children with cancer and a diagnosis of VTE at King Hussein Cancer Center in Jordan. Variables reviewed are patients’ clinical characteristics, treatment for cancer, and anticoagulation therapy. Results: Between January 2011 and December 2018, a total of 45 patients fulfilled the inclusion criteria, and the median age was 10.4 (0.8-17.9) years. The most common underlying diagnosis was acute lymphoblastic leukemia (n = 13, 29%). At the time of VTE, 29 (64.4%) patients were receiving chemotherapy, and eight (17.8%) had a central venous catheter (CVC). The majority of patients (n = 37, 82%) developed VTE within 30 days of hospitalization. Thrombosis mostly involved the extremities (n = 23, 51%) and sagittal vein (n = 12, 26.7%). All patients were treated with low-molecular-weight heparin (LMWH), complicated by bleeding in three (6.6%) patients. Conclusion: In contrast to adults, VTE in pediatric cancer patients is more associated with chemotherapy and recent hospitalization. LMWH is a safe and effective therapy for children with cancer who develop VTE.
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12
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Endothelial dysfunction and thromboembolism in children, adolescents, and young adults with acute lymphoblastic leukemia. Leukemia 2021; 36:361-369. [PMID: 34389803 DOI: 10.1038/s41375-021-01383-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/22/2021] [Accepted: 08/04/2021] [Indexed: 02/06/2023]
Abstract
Endothelial dysfunction has not previously been investigated as a thrombogenic risk factor among patients with acute lymphoblastic leukemia (ALL), known to be at high risk of thromboembolism. We retrospectively explored the association between three circulating biomarkers of endothelial dysfunction (thrombomodulin, syndecan-1, VEGFR-1) measured in prospectively collected blood samples and risk of thromboembolism in 55 cases and 165 time-matched controls, treated according to the NOPHO ALL2008 protocol. In age-, sex-, and risk group-adjusted analysis, increasing levels of thrombomodulin and VEGFR-1 were independently associated with increased odds of developing thromboembolism (OR 1.37 per 1 ng/mL [95% CI 1.20‒1.56, P < 0.0001] and OR 1.21 per 100 pg/mL [95% CI 1.02‒1.21, P = 0.005], respectively). These associations remained significant when including only samples drawn >30 days before thromboembolic diagnosis. Thrombomodulin levels were on average 3.2 ng/mL (95% CI 2.6-8.2 ng/mL) higher in samples with measurable asparaginase activity (P < 0.0001). Among single nucleotide variants located in or neighboring coding genes for the three biomarkers, none were significantly associated with odds of thromboembolism. If results are validated in another cohort, thrombomodulin and VEGFR-1 could serve as predictive biomarkers, identifying patients in need of preemptive antithrombotic prophylaxis.
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13
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Jarvis KB, Andersson NG, Giertz M, Järvelä L, Lindinger O, Långström S, Niinimäki R, Palmu S, Trakymiene SS, Tuckuviene R, Vepsäläinen K, Ranta S, Frisk T. Asymptomatic Right Atrial Thrombosis After Acute Lymphoblastic Leukemia Treatment. J Pediatr Hematol Oncol 2021; 43:e564-e566. [PMID: 32555028 DOI: 10.1097/mph.0000000000001848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/28/2020] [Indexed: 11/25/2022]
Abstract
Right atrial thrombosis is a rare, but potentially serious complication of acute lymphoblastic leukemia treatment. We conducted a retrospective multicenter study to assess the incidence, treatment, and outcome of asymptomatic right atrial thrombosis detected at routine echocardiography of children after acute lymphoblastic leukemia treatment in the Nordic and Baltic countries. Eleven (2.7%, 95% confidence interval, 1.4-4.9) of 406 patients had asymptomatic right atrial thrombosis, ranging from 10 to 25 mm at detection. Three patients were treated with anticoagulation. None of the thromboses affected cardiac function, and they showed neither sign of progress nor spontaneous or treatment-related regress at follow-up.
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Affiliation(s)
- Kirsten B Jarvis
- Departments of Pediatric Hematology and Oncology
- Pediatric Research, Oslo University Hospital
- The Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nadine G Andersson
- Department for Pediatric Hematology and Oncology, Skåne University Hospital, Lund
| | - Mia Giertz
- Department of Pediatric Hematology and Oncology, Uppsala University Hospital
- Department of Women's and Children's Health, University of Uppsala, Uppsala
| | - Liisa Järvelä
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital
- Department of Clinical Sciences, University of Turku, Turku
| | | | - Satu Långström
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Children's Hospital, Helsinki University Hospital, Helsinki
| | - Riitta Niinimäki
- PEDEGO Research Unit, University of Oulu
- Department of Children and Adolescents, Oulu University Hospital, Oulu
| | - Sauli Palmu
- Faculty of Medicine and Health Technology, Tampere University
- Center for Child Health Research, Tampere University and Department of Pediatrics, Tampere University Hospital, Tampere
| | - Sonata S Trakymiene
- Center for Pediatric Oncology and Hematology, Children's Hospital, Vilnius University Hospital Santaros Klinikos
- Clinic of Children's Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ruta Tuckuviene
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Kaisa Vepsäläinen
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Susanna Ranta
- Astrid Lindgren Children's Hospital, Karolinska University Hospital
- Department of Women's and Children's Health, Karolinska Insitutet, Stockholm, Sweden
| | - Tony Frisk
- Astrid Lindgren Children's Hospital, Karolinska University Hospital
- Department of Women's and Children's Health, Karolinska Insitutet, Stockholm, Sweden
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14
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Dynamic Changes in the Ability to Release Neutrophil ExtraCellular Traps in the Course of Childhood Acute Leukemias. Int J Mol Sci 2021; 22:ijms22020821. [PMID: 33467555 PMCID: PMC7829911 DOI: 10.3390/ijms22020821] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 02/06/2023] Open
Abstract
Acute leukemias, the most common cancers in children, are characterized by excessive proliferation of malignant progenitor cells. As a consequence of impaired blood cell production, leukemia patients are susceptible to infectious complications—a major cause of non-relapse mortality. Neutrophil extracellular traps (NETs) are involved in various pathologies, from autoimmunity to cancer. Although aberrant NETs formation may be partially responsible for immune defects observed in acute leukemia, still little is known on the NET release in the course of leukemia. Here, we present the first comprehensive evaluation of NETs formation by neutrophils isolated from children with acute leukemia in different stages of the disease and treatment stimulated in vitro with phorbol 12-myristate 13-acetate (PMA), N-formyl-methionyl-leucyl-phenylalanine (fMLP), and calcium ionophore (CI). NETs release was measured using quantitative fluorescent method and visualized microscopically. In this setting, NETs release was significantly impaired in leukemic children both at the diagnosis and during the treatment, and full restoration of neutrophil function was achieved only after successful completion of the leukemia treatment. We suggest that neutrophil function impairment may result from both disease- and treatment-related factors. In this context, deficient innate immune response observed in acute leukemia patients may be present regardless of neutrophil count and contribute to secondary immunodeficiency observed in this population.
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15
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A pilot study of procoagulant platelet extracellular vesicles and P-selectin increase during induction treatment in acute lymphoblastic leukaemia paediatric patients: two new biomarkers of thrombogenic risk? J Thromb Thrombolysis 2020; 51:711-719. [PMID: 33247807 DOI: 10.1007/s11239-020-02346-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 01/19/2023]
Abstract
In paediatric acute lymphoblastic leukaemia (ALL), focus has shifted towards preventing treatment-related complications, including venous thromboembolism, the cause of significant mortality and morbidity. To better understand thrombogenic mechanisms during induction treatment, we studied the number, origin and procoagulant activity of extracellular vesicles (EVs) and P-selectin level throughout the induction course in 24 paediatric patients. EVs were mainly of platelet origin. We observed a significant increase in EV number, in platelet EV number and P-selectin level throughout the induction course. There was a correlation between higher EV and platelet EV number, P-selectin level, higher platelet count and leucocyte count. We also observed a correlation between higher EV procoagulant activity and higher platelet count and leucocyte count and higher P-selectin level. Older age and T phenotype were associated with a higher EV procoagulant activity. Platelet EV generation may play a role in thrombogenic complications in ALL patients and could serve as a biomarker to identify patients with a high risk of thrombosis. As a marker of platelet activation, P-selectin may be another relevant marker with the advantage of being easier to analyse in clinical practice.
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16
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Campos LR, Petroli M, Sztajnbok FR, da Costa ES, Brandão LR, Land MGP. Risk factors for the development of hospital-acquired pediatric venous thromboembolism-Dealing with potentially causal and confounding risk factors using a directed acyclic graph (DAG) analysis. PLoS One 2020; 15:e0242311. [PMID: 33186402 PMCID: PMC7665816 DOI: 10.1371/journal.pone.0242311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 11/01/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction Hospital-acquired venous thromboembolism (HA-VTE) in children comprises multiple risk factors that should not be evaluated separately due to collinearity and multiple cause and effect relationships. This is one of the first case-control study of pediatric HA-VTE risk factors using a Directed Acyclic Graph (DAG) analysis. Material and methods Retrospective, case-control study with 22 cases of objectively confirmed HA-VTE and 76 controls matched by age, sex, unit of admission, and period of hospitalization. Descriptive statistics were used to define distributions of continuous variables, frequencies, and proportions of categorical variables, comparing cases and controls. Due to many potential risk factors of HA-VTE, a directed acyclic graph (DAG) model was created to identify confounding, reduce bias, and increase precision on the analysis. The final model consisted of a DAG-informed conditional logistic regression. Results In the initial conventional univariable model, the following variables were selected as potential risk factors for HA-VTE: length of stay (LOS, days), immobility, ICU admission in the last 30 days, LOS in ICU, infection, central venous catheter (CVC), number of CVCs placed, L-asparaginase, heart failure, liver failure, and nephrotic syndrome. The final model using the set of variables selected by DAG analysis revealed LOS (OR = 1.106, 95%CI = 1.021–1.198, p = 0.013), L-asparaginase (OR = 26.463, 95%CI = 1.609–435.342, p = 0.022), and nephrotic syndrome (OR = 29.127, 95%CI = 1.044–812.508, p = 0.004) as independent risk factors for HA-VTE. Conclusion The DAG-based approach was useful to clarify the influence of confounders and multiple causalities of HA-VTE. Interestingly, CVC placement—a known thrombotic risk factor highlighted in several studies—was considered a confounder, while LOS, L-asparaginase use and nephrotic syndrome were confirmed as risk factors to HA-VTE. Large confidence intervals are related to the sample size; however, the results were significant.
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Affiliation(s)
- Leonardo Rodrigues Campos
- Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Division of Pediatric Rheumatology, Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói - Rio de Janeiro, Brazil
| | - Maurício Petroli
- Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Flavio Roberto Sztajnbok
- Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Division of Pediatric Rheumatology, Hospital Universitário Pedro Ernesto, Rio de Janeiro, Brazil
| | - Elaine Sobral da Costa
- Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Rodrigues Brandão
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Gerardin Poirot Land
- Department of Pediatrics, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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17
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Poh C, Brunson A, Keegan T, Wun T, Mahajan A. Incidence of Upper Extremity Deep Vein Thrombosis in Acute Leukemia and Effect on Mortality. TH OPEN 2020; 4:e309-e317. [PMID: 33134806 PMCID: PMC7593117 DOI: 10.1055/s-0040-1718883] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/14/2020] [Indexed: 12/21/2022] Open
Abstract
The cumulative incidence, risk factors, rate of subsequent venous thromboembolism (VTE) and bleeding and impact on mortality of isolated upper extremity deep vein thrombosis (UE DVT) in acute leukemia are not well-described. The California Cancer Registry, used to identify treated patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) diagnosed between 2009 and 2014, was linked with the statewide hospitalization database to determine cumulative incidences of UE DVT and subsequent VTE and bleeding after UE DVT diagnosis. Cox proportional hazards regression models were used to assess the association of UE DVT on the risk of subsequent pulmonary embolism (PE) or lower extremity deep vein thrombosis (LE DVT) and subsequent bleeding, and the impact of UE DVT on mortality. There were 5,072 patients identified: 3,252 had AML and 1,820 had ALL. Three- and 12-month cumulative incidences of UE DVT were 4.8% (95% confidence interval [CI]: 4.1–5.6) and 6.6% (95% CI: 5.8–7.5) for AML and 4.1% (95% CI: 3.2–5.1) and 5.9% (95% CI: 4.9–7.1) for ALL, respectively. Twelve-month cumulative incidences of subsequent VTE after an incident UE DVT diagnosis were 5.3% for AML and 12.2% for ALL. Twelve-month cumulative incidences of subsequent bleeding after an incident UE DVT diagnosis were 15.4% for AML and 21.1% for ALL. UE DVT was associated with an increased risk of subsequent bleeding for both AML (hazard ratio [HR]: 2.07; 95% CI: 1.60–2.68) and ALL (HR: 1.62; 95% CI: 1.02–2.57) but was not an independent risk factor for subsequent PE or LE DVT for either leukemia subtype. Isolated incident UE DVT was associated with increased leukemia-specific mortality for AML (HR: 1.42; 95% CI: 1.16–1.73) and ALL (HR: 1.80; 95% CI: 1.31–2.47). UE DVT is a relatively common complication among patients with AML and ALL and has a significant impact on bleeding and mortality. Further research is needed to determine appropriate therapy for this high-risk population.
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Affiliation(s)
- Christina Poh
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States.,Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Ann Brunson
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States
| | - Theresa Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States
| | - Ted Wun
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States.,UC Davis Clinical and Translational Science Center, University of California, Davis, Sacramento, California, United States
| | - Anjlee Mahajan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States
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18
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Instituting a New Central Line Policy to Decrease Central Line-associated Blood Stream Infection Rates During Induction Therapy in Pediatric Acute Lymphoblastic Leukemia Patients. J Pediatr Hematol Oncol 2020; 42:433-437. [PMID: 32068652 DOI: 10.1097/mph.0000000000001748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children with acute lymphoblastic leukemia (ALL) require central lines to facilitate their care. Peripherally inserted central catheters (PICCs) may have lower rates of central line-associated bloodstream infections (CLABSIs) versus other central lines. OBJECTIVES The objective of this study was to compare the CLABSI rate in the first month of therapy after initiating a policy to place PICCs in new patients with severe neutropenia (SN) and Mediports in those with moderate-to-no neutropenia. We also examined thrombosis rates. DESIGN/METHOD We prospectively gathered data on new patients for 2.5 years following the policy change and retrospectively for the 2 years prior and compared rates of CLABSIs and thrombosis. RESULTS CLABSIs decreased in SN patients from 7.52/1000 to 3.11/1000 line days (P=0.33). The CLABSI rate for all patients with SN who had a Mediport was 13.39/1000 versus 4.08/1000 line days for those that received PICCs (P=0.15). The thrombosis rate for Mediport patients was 3.13 clots/1000 versus 7.65/1000 line days for PICC patients, but the difference was not significant (P= 0.11). CONCLUSION The differences observed suggest that placing PICCs versus Mediports in new ALL patients with SN may result in a lower incidence of CLABSIs in the first month of therapy without a significant increase in thrombosis.
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19
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Cohen O, Levy-Mendelovich S, Ageno W. Rivaroxaban for the treatment of venous thromboembolism in pediatric patients. Expert Rev Cardiovasc Ther 2020; 18:733-741. [DOI: 10.1080/14779072.2020.1823218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Tisch Cancer Institue, Icahn School of Medicine, Mount Sinai Hospital, NY, USA
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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20
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Barg AA, Kenet G. Cancer-associated thrombosis in pediatric patients. Thromb Res 2020; 191 Suppl 1:S22-S25. [PMID: 32736773 DOI: 10.1016/s0049-3848(20)30392-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 12/21/2022]
Abstract
Childhood malignancy and especially acute lymphoblastic leukemia are increasingly associated with thromboembolism. The etiology of pediatric cancer associated thrombosis is multifactorial and may reflect a tumor mass effect, tumor thrombi, alterations of the hemostatic system, treatment-related hazards (e.g. procoagulant changes induced by chemotherapy), presence of central venous lines and comorbidities (e.g. inherited thrombophilia). With over 80% cure rates of childhood cancer, strategies for prevention as well as for early diagnosis and optimal treatment of thromboembolism in children with malignancies are of major importance. While the use of therapeutic low molecular weight heparin prevails, prospective studies regarding guidelines for treatment or prevention are currently lacking. This review will address the epidemiology, etiology and risk factors for thrombosis, describe the presently available evidence associated with current therapy, and offer a glimpse into future treatment options.
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Affiliation(s)
- Assaf Arie Barg
- The Israeli National Hemophilia Center and Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel
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- The Israeli National Hemophilia Center and Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel.
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Venous Thromboembolism After Peripherally Inserted Central Catheters Placement in Children With Acute Leukemia: A Single-center Retrospective Cohort Study. J Pediatr Hematol Oncol 2020; 42:e407-e409. [PMID: 32427704 DOI: 10.1097/mph.0000000000001832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To explore the incidence rate and characteristics of symptomatic venous thromboembolism (VTE) after peripherally inserted central catheters (PICC) placement in children with acute leukemia (AL). METHODS The authors performed a retrospective study aiming at children admitted to Pediatric Blood Diseases Center with a new diagnosis of AL and received a PICC insertion, collected the clinical materials of all venous thrombosis cases, and analyzed the incidence rate and characteristics in various types of AL. RESULTS From September 2007 to December 2018, a total of 2423 patients got PICCs at least once, of whom 29 patients experienced thrombosis events and the overall incidence rate of symptomatic VTE after PICC insertion was 1.2%. Deep venous thrombosis accounted for the majority with 75.9%. Seven cases of cerebral venous sinus thrombosis were documented and they all developed in patients with acute lymphoblastic leukemia (ALL). No pulmonary embolism was detected. Patients with acute myeloid leukemia (AML) had an identical risk of thrombosis to patients with acute lymphoblastic leukemia (ALL) (1.7% vs. 1.09%, P>0.05). All thrombi in patients with AML were located on the upper extremity, whereas in the ALL group about half of the thromboembolism developed in other locations. There were no statistical differences between patients in different clinical trials of the ALL group (0.7% vs. 1.6%, P>0.05). CONCLUSIONS The incidence rates of symptomatic VTE after PICC placement in children with AL in our center were relatively low and acceptable. For patients with AML, PICC placement plays the most important role in venous thrombosis. However, in patients with ALL, the potential risk factors were more complex.
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