Adjuvant antiestrogen treatment with tamoxifen in postmenopausal women with breast cancer: a longitudinal study of blood coagulation and fibrinolysis

Risk factors of catheter-related thrombosis in early-stage breast cancer patients: a single-center retrospective study

Purpose

Totally implantable venous access devices (TIVADs) are widely used in cancer patients. The main purpose of our study is to observe the incidence and identified risk factors of catheter-related thrombosis (CRT) in breast cancer patients with TIVAD.

Patients and methods

We performed a retrospective cohort study of consecutive breast cancer patients who received the ultrasound-guided TIVAD implantation for the administration of chemotherapy from 2013 to 2016. The primary outcome was CRT (both symptomatic and asymptomatic detected by ultrasound). Univariable and multivariable logistic regression analyses were used to identify the risk factors for breast cancer TIVAD-related CRT.

Results

A total of 209 breast cancer patients with a newly implanted TIVAD for chemotherapy were included in this study. The average time of port duration was 7 months. Of the enrolled 209 patients, 33 patients (15.8%) had CRT, 2 of the 33 cases were symptomatic (1 pulmonary embolism, 1 deep-venous thrombosis [DVT]), the other 31 cases were asymptomatic detected by routine ultrasound examination of the catheter-associated vein before TIVAD removal with all cycles of chemotherapy completed. In total, 19 (57.6%) of CRT patients underwent directly TIVAD removal without any further treatments, 14 patients received anticoagulation treatments for 3–30 days followed by TIVAD removal. No DVT event was observed within at least 1.5 years of follow-up. In the multiple-variable analysis, tumor size >2 cm (OR 2.735, 95% CI 1.042–7.177; P=0.032), positive HbsAg (OR 2.803 95% CI 1.027–7.856; P=0.047) and low-density lipoprotein (LDL) >3.6 mmol/L (OR 2.360, 95% CI 1.059–5.351; P=0.040) were the significant independent risk factors of breast cancer TIVAD-related CRT.

Conclusion

CRT is a common complication in breast cancer patients with TIVAD for chemotherapy. Tumor size, HbsAg status and LDL level were independent predictors of breast cancer for TIVAD-related CRT. Removal of the port without anticoagulation treatments might be a feasible choice for asymptomatic TIVAD-related CRT.

Longitudinal analysis of hemostasis biomarkers in cancer patients during antitumor treatment

ESSENTIALS: Hemostasis biomarkers impact thrombosis occurrence and survival in cancer patients. We performed a longitudinal analysis of hemostatic parameters in 112 cancer patients. Hemostatic parameters are associated with disease state, patients' prognosis, and the risk of VTE. The procoagulant state exists not only at diagnosis, but also during the course of disease.

BACKGROUND

Hemostasis biomarkers are known to have an impact on venous thromboembolism (VTE) occurrence and survival in cancer patients.

OBJECTIVES

As there are almost no data on longitudinal changes, we aimed to evaluate those in the present prospective observational study during chemotherapy and the course of disease.

PATIENTS/METHODS

Patients with cancer of the brain (n = 39), lung (n = 41), colon (n = 15) or pancreas (n = 17) were included before initiation of antitumor therapy. Blood samples for determination of factor VIII, thrombin peak height, D-dimer, F1 + 2 , fibrinogen and soluble P-selectin (sP-selectin) were drawn on a monthly basis. The study endpoints were death, VTE occurrence, or completion of the study period.

RESULTS

Overall, 546 blood samples of 112 patients were analyzed. D-dimer and sP-selectin levels were significantly higher in patients with distant metastasis than in those without. Patients with complete remission had significantly lower levels of F1 + 2 , D-dimer and fibrinogen. Peak height thrombin levels showed a decrease over time in all tumor types. Levels of biomarkers behaved differently in the various tumor types. Patients who developed VTE (n = 14) showed increasing levels of FVIII, sP-selectin, and D-dimer. At the last blood sampling time-point before VTE occurrence, in 13 patients the D-dimer level was above the median, and in seven of these patients it was even above the 75th percentile; however, the individual course was highly variable. Regarding survival, steadily increased FVIII, sP-selectin and D-dimer levels were associated with higher mortality.

CONCLUSIONS

Hemostatic parameters show an association with disease state, prognosis, and the risk of VTE, not only at diagnosis, but also during the course of antineoplastic treatment.

An overview of coagulation disorders in cancer patients

A diversity of coagulation disorders in cancer patients arise from tumor-specific growth characteristics, neoangiogenesis with impaired endothelial lining, defective myelopoiesis, hypoproteinemia or metastatic lesions growth with organ dysfunction. Recent investigations have found a clinically relevant correlation of coagulation disorders and tumor growth. These prompted new therapeutic strategies focused on growth factors with the aim to control tumor metastasis, particularly if used for the treatment of micrometastatic disease. However, such treatment may lead to the life threatening coagulation imbalance. A coagulation homeostasis may become further impaired after nonsurgical cancer therapy, especially after preoperative irradiation, which produces lesions precipitating both bleeding and thrombosis. Anticancer chemotherapy may affect liver function and decrease the synthesis of both procoagulation and anticoagulation factors. The most of chemotherapeutic protocols affect platelet synthesis, which arises as a principal dose-limiting side effect. It was observed both during combined systemic chemotherapy and local antitumor therapy. Although the side effects produced by chemotherapy are reversible, endothelial lesions may persist for many years after the anticancer treatment. Instead of cancer patients, there's a growing cohort of patients with nonmalignant diseases who use cytostatics in the perioperative period, and are candidates for surgical procedures not related to their malignant disease, i.e. hernia repair. In this patient population a special attention must be paid to the preoperative evaluation of coagulation status and thromboprophylaxis. This overview reminds the most common coagulation disorders in cancer patients in the perioperative period. It emphasizes the need for proper patient monitoring which may facilitate the diagnostics and treatment of cancer-related coagulation disorders in the perioperative setting.

Effect on survival of treatment-associated venous thromboembolism in newly diagnosed multiple myeloma patients

Venous thromboembolism (VTE) is a cancer complication associated with poor survival. We have analyzed the prognostic impact of the development of a thrombotic episode in newly diagnosed multiple myeloma patients who received chemotherapy either with or without thalidomide on our Total Therapy 2 protocol. Of 668 patients enrolled, 155 developed VTE complication during treatment. The overall and event-free survival of patients who experienced VTE was not inferior. Of interest, we observed that patients who received intensive chemotherapy without thalidomide but developed a thrombosis experienced a significantly longer event-free survival compared with those without VTE (P = 0.02). Our observation suggests a possible beneficial effect of anticoagulation on survival in patients treated for myeloma.

Acute bilateral pulmonary emboli occurring while on adjuvant aromatase inhibitor therapy with anastrozole: case report and review of the literature

Hormonal therapy is the mainstay of adjuvant treatment for women with early-stage estrogen receptor-positive breast cancer. Recently, the aromatase inhibitors have moved to the forefront of adjuvant hormonal therapy, however, the adverse effects of these agents are not yet fully understood. It is generally accepted that tamoxifen, but not the aromatase inhibitors, is associated with an increased risk of thrombosis in women with breast cancer. Studies comparing aromatase inhibitors to tamoxifen in the adjuvant setting have reported a lower rate of venous thromboembolism with the aromatase inhibitors, yet the incidence of venous thromboembolism with these new agents is higher than that expected in the general population. Here we report a case of acute bilateral pulmonary emboli occurring while on adjuvant aromatase inhibitor therapy with anastrozole, and review the literature on the incidence of venous thromboembolism during the use of aromatase inhibitors in the adjuvant setting.

Tamoxifen-induced tissue factor pathway inhibitor reduction: a clue for an acquired thrombophilic state?

BACKGROUND

Current understanding of hemostatic systems enables us to better explore the enigmatic pathobiology of tamoxifen (TAM)-induced thrombotic diathesis. We have therefore aimed to assess the hemostatic changes in breast cancer patients receiving TAM on an adjuvant basis.

PATIENTS AND METHODS

The study population consisted of 43 female patients with hormone receptor-positive breast cancer who received TAM 20 mg/day as part of their adjuvant treatment. Mean age was 52+/-12 years (range 25-74). Twenty-one patients (49%) were premenopausal. Plasma samples were collected prior to and following 6 months of TAM therapy and were assayed for total tissue factor pathway inhibitor (TFPI), free TFPI, lipid-bound TFPI, thrombomodulin, D dimer, activated protein C resistance (APC res), factors VIIa, II, V, VII and X, and global fibrinolytic capacity (GFC).

RESULTS

Median total TFPI decreased significantly from 48.5 ng/ml to 36.2 ng/ml (P=0.001), free TFPI from 10 to 7.6 ng/ml (P=0.001) and lipid-bound TFPI from 39.1 to 28.7 ng/ml (P=0.001). There were significant decreases in the levels of factor II (P=0.03), factor V (P=0.001), factor VII (P=0.06), thrombomodulin (P=0.01) and D dimer (P=0.001). However, APC res times were significantly prolonged (P=0.04). The remaining parameters that we have studied were not significantly affected.

CONCLUSION

Our findings suggest that TAM tends to activate the coagulation pathway by counteracting major molecules involved in coagulation inhibition, namely TFPI and TM. As reflected by unchanged GFC, the drug appears to impair the expected compensatory activation of the fibrinolytic system, which removes fibrin polymers resulting from coagulation activation.

Inherited and acquired risk factors for venous thromboembolic disease among women taking tamoxifen to prevent breast cancer

PURPOSE

Venous thromboembolism (VTE) is of particular concern in women receiving tamoxifen in a chemopreventive setting. We investigate the association between acquired and inherited risk factors for VTE in the International Breast Cancer Intervention Study (IBIS-I) trial of tamoxifen prophylaxis for women at increased risk of breast cancer.

METHODS

We used a nested case-control study design to investigate the role of tamoxifen and acquired risk factors in the risk of developing a VTE.

RESULTS

Tamoxifen was associated with a significantly increased risk of developing a major VTE (odds ratio [OR], 2.1; 95% CI, 1.1 to 4.1). Women who had surgery, immobilization, or fracture in the previous month had a greatly increased risk of developing a major VTE (OR, 4.7; 95% CI, 2.2 to 10.1). Prothrombin and factor V Leiden mutations were found exclusively among control women: factor V Leiden in eight of 159 control women (5.0%) and the prothrombin mutation in three control women (1.9%). Thirty-five women with a VTE and a blood sample were negative for these mutations. The upper one-sided 97.5% CI for the OR of having either mutation was 1.87. Being overweight, smoking, or taking hormone replacement therapy was not associated with VTE in this study, but the CIs were wide.

CONCLUSION

Tamoxifen and prior surgery, fracture, or immobilization were associated with a significantly increased risk of developing a VTE. Factor V Leiden and prothrombin mutations were not associated with thrombosis in this population.

Effect of earthworm (G-90) extract on formation and lysis of clots originated from venous blood of dogs with cardiopathies and with malignant tumors

The stability of homeostasis is important to keep a balance between coagulation and fibrinolysis. A disorder of homeostasis leads to different physiological changes and causes different diseases such as cardiopathies and malignant tumors. Cardiopathies is characterized by a hypercoagulation. In the malignant tumors, besides the hypercoagulation due to plasminogen activators (PA) formed inside the tumor, a disorder of homeostasis leads also to acceleration of the fibrinolysis. The variety of internal and external factors in both cases determine the deviation of time for the clots formation, as well as the lyses of blood and fibrin clots. In this study the venous blood as well as the blood and the fibrin clots, derived from healthy dogs, the dogs with cardiopathies and with malignant tumors, were examined for the time of coagulation and fibrinolysis by adding different substances. In these experiments we used a glycolipoprotein extract from earthworm tissue homogenate (G-90) and the proteolytic enzymes P I and P II, isolated from G-90. The efficacy of the tested substances was comparable with the clinically administered anticoagulants. The most significant differences in clotting time among the three tested groups of dogs were obtained by application of the original G-90. The results suggest a possibility that G-90, along with the fibrinolytic enzymes and other biologically active factors, also contains a factor that decelerates the formation of clot in a specific medium, such as the blood from the dogs with malignant tumors.

Cerebral embolism and hormone replacement therapy

Few studies have focused on the relationship between hormone replacement therapy (HRT) for postmenopausal women or those with breast cancer and the occurrence of cerebral embolism. Results are conflicting as to whether there is a link between the two. We describe three patients who experienced cerebral embolism during HRT. A 73-year-old woman had a transient ischemic attack (TIA) 6 years prior to the present admission. She then took HRT oestrogen plus medroxyprogesterone acetate for about 6 years. The HRT had been prescribed by a gynaecologist for amelioration of postmenopausal symptoms. Six years after beginning HRT, she experienced sudden onset left hemiparesis due to cerebral embolism. Two other patients had been taking HRT for breast cancers. One, a 47-year-old woman, had taken medroxyprogesterone acetate for more than one year, for recurrence of breast cancer. She had developed sudden complete left hemiparesis due to an embolism at the carotid bifurcation. The other patient, a 72-year-old woman who was taking tamoxifen citrate for prevention of breast cancer relapse, experienced cerebral embolism just 2 months after beginning tamoxifen. The risk of cerebral embolism in those on HRT should be emphasized, along with the beneficial effects in terms of postmenopausal symptoms and prevention of breast cancer recurrence.

Acquired thrombophilic syndromes

As the biochemical mechanisms of hypercoagulable states are revealed, the syndromes of venous thromboembolism have been increasingly associated with specific aberrations. Most of these changes involve an increase in procoagulant potential, for example, by activation of the coagulation cascade, or by a defect or decrease in natural inhibitors of clotting. Similar abnormalities of the fibrinolytic pathways may contribute, as can loss of inhibitory mechanisms of endothelial cells, as well as changes in vascular anatomy and rheologic patterns of blood flow. All of these factors can directly influence thrombus formation and/or the physiologic response to the thrombus.(1)