Risk of venous thromboembolism in people with lung cancer: a cohort study using linked UK healthcare data

Prospective assessment of venous thromboembolism in lung cancer patients using a standardized screening protocol

Venous thromboembolism (VTE) is highly prevalent in cancer patients. While its actual incidence remains disparate among studies, specific subpopulations, such as lung cancer patients, might be at an increased risk. We aimed to assess the impact of a screening protocol in determining both the incidence and risk factors for VTE and evaluate the usefulness of predictive biomarkers and risk stratification tools in lung cancer patients. For this purpose, we designed a prospective cohort study including all consecutive, newly diagnosed lung cancer patients between October 2023 and April 2024 in a tertiary center and assessed each patient using a standardized screening protocol. VTE screening included baseline and 3-month reassessment of coagulation tests, D-dimer levels, and imaging (duplex ultrasound of the lower limbs for deep vein thrombosis screening and contrast-enhanced thoracic computed tomography for pulmonary embolism screening). A total of 102 patients were included, of which 16 (15.7%) were diagnosed with VTE. VTE was more frequent in males (p=0.031), patients with COPD (p=0.004), and patients with metastatic disease (p=0.038), particularly those under immunotherapy (p=0.026). Patients with VTE presented a D-dimer concentration more than three times higher at baseline and fivefold the levels observed in non-VTE patients at 3 months (p=0.002). Paired with Khorana scores, D-dimer concentration 4.5 mg/L at 3 months improved the predictive capacity of this VTE risk assessment tool in patients under active treatment. Active VTE screening yielded a significant increase in diagnosis, suggesting the incidence of this complication in newly diagnosed lung cancer patients is underestimated. Risk assessment tools can be enhanced by the addition of D-dimer-based parameters.

Betanin inspired zinc oxide nanoparticles: The potential antioxidant and anticancer activity against human lung cancer cell line (A549)

BACKGROUND INFORMATION

Lung cancer is the most frequently reported disease on a global scale. The bioactive substances are less successful in specifically destroying cancer cells. To prevent early inactivation and ensure targeted delivery of bioactive chemicals to cancer cells. Betanin is known as nitrogenous water-soluble molecule which possess anti-inflammatory, hepatoprotective, antioxidant, and anticancer properties.

AIM OF THE STUDY

This work evaluates the anti-cancer and anti-oxidant properties of Betanin coated zinc oxide nanoparticles on the A549 lung cancer cell line.

MATERIALS AND METHODS

In the current work, Betanin coated Zinc oxide nanoparticles (Betanin coated ZnO NPs) were made utilizing Betanin, a phytochemical. SEM, FTIR, DLS, and UV-Vis were used to evaluate their properties. Trypan blue and MTT were used to confirm cell survival and cytotoxicity of ZnO nanoparticles at various dosages. The morphological evaluation of A549 cells was investigated by phase contrast microscopy and apoptosis by propidium iodide staining. The membrane integrity of mitochondria was investigated by rhodamine 123 staining and observed under fluorescence microscope. The anti-oxidant ability of ZnO nanoparticles was analyzed by level of catalase, glutathione, nitric oxide, lipid peroxidation, and superoxide dismutase using UV spectrophotometric analysis. Studies on gene expression (Bcl2, P53and BAX) were conducted to assess the molecular mechanism of apoptosis mediated by synthesized nanoparticle and level of matrix metalloproteinase -2 (MMP-2) by gelatin zymography.

RESULTS

At the peak of 383 nm in the UV band, zinc oxide NP synthesis was confirmed. The FT-IR data demonstrated that zinc oxide nanoparticles were effectively coated with Betanin and by dynamic light scattering analysis confirmed particle size to be 100.8 nm. The presence of cubic, spherical, and platelet-shaped zinc oxide nanoparticles has been observed by SEM analysis. The nanoparticles of zinc oxide (ZnO) were synthesized chemically and exhibited decreasing cell viability and increasing cytotoxicity and apoptosis in dose dependent manner. The levels of LPO activity increased significantly and NO, antioxidant enzymes (GSH, SOD, and CAT) activity decreased significantly (P <0.0001). Our results demonstrated that A549 cells treated with Betanin loaded ZnO nanoparticles to prevent oxidation by scavenging free radicals and increased levels of gene expression related to apoptotic proteins BAX, p53 and decreased level of expression in Bcl2. Further, level of matrix metalloproteinase -2 (MMP-2) decreased with increase in concentration of nanoparticle.

CONCLUSION

As per the research described above, lung cancer cells were effectively targeted by the anticancer and antioxidant abilities of ZnO nanoparticles inspired by Betanin (A549).

Non-bacterial Thrombotic Endocarditis in Lung Cancer: A Systematic Review

INTRODUCTION

Non-bacterial Thrombotic Endocarditis (NBTE) is a rare condition characterized by aseptic vegetations of the heart valves, predisposing to valvular dysfunction and end-organ infarction. Lung Cancer (LC) is amongst the most common malignancies associated with NBTE.

METHODS

PubMed/MEDLINE was searched from database inception until January 2024, pairing Non-bacterial Thrombotic Endocarditis (NBTE) and related terms with "Lung Cancer (LC)". Reports were included if patients had both NBTE and lung cancer. The risk of bias was assessed using Mixed Methods Analysis Testing (MMAT).

RESULTS AND DISCUSSION

32 patients with an average age of 59y +/- 11.6 were included from 31 peer-reviewed publications, with significant findings as below: • The majority (47%) of patients were admitted with stroke. • The most commonly affected valve was aortic (51%), followed by mitral (43%), and tricuspid (5%). • At diagnosis of NBTE, 86% of patients had stage IV cancer. • Multi-organ infarct was common (61%), with the brain most often affected (40%). • Treatment of NBTE included antibiotics (86%), anticoagulation (50%), and cardiac surgery (6%). • Treatment of LC included traditional chemotherapy (30.7%), radiation (16%), tyrosine kinase inhibitors (11.5%), lobectomy (6%), and immunotherapy (3.8%). • Overall mortality rate was 77%. • Mortality rate was 38% in patients treated with chemotherapy and 91% in patients who did not receive chemotherapy. • Mortality rate stratified by anticoagulant: unfractionated heparin (85.7%), DOAC (75%), and LMWH (20%).

CONCLUSION

High clinical suspicion for NBTE in patients presenting with LC and thromboembolic phenomena can lead to changes in treatment and improved clinical outcomes.

Incidence and risk factors of VTE in lung cancer: a meta-analysis

BACKGROUND

Lung cancer has maintained a high prevalence and mortality. Besides, venous thromboembolism (VTE) is the third most common disease of cardiovascular disease. Lung cancer with VTE usually influenced the overall survival in the follow-up. In the development of lung cancer, vigilance against and early diagnosis of VTE is of significance.

METHODS

We searched the databases of PubMed, Web of Science, Embase and Cochrane for related research up to 30 November 2023 and extracted information of incidence, odds ratio (OR), hazard ratio (HR) and their 95% confidence intervals (CIs), for evaluating the incidence of VTE and its risk factors.

RESULTS

A total of 54 articles and 873,292 records were included in our study. The pooled incidences of VTE and PE were 6% and 3%, respectively. Subgroup analysis revealed that the tumour, node and metastasis (TNM) stage (HR= 5.43, 95% CI: 2.42, 12.22), metastasis (HR= 2.67, 95% CI: 1.35, 5.29) and chemotherapy (HR= 2.27, 95% CI: 1.11, 4.65) had major influence on VTE occurrence.

CONCLUSIONS

Lung cancer complicated with VTE is unignorable, and its occurrence varies widely by tumour staging, tissue type and treatment. The results may aid in clinical decision-making about lung cancer in higher risk with VTE and weather receiving anticoagulant prophylaxis.

Prevalence and clinical characteristics of venous thromboembolism in patients with lung cancer: a systematic review and meta-analysis

Background

The prevalence of venous thromboembolism (VTE) is high in patients with cancer and can often present as the first symptom of malignancy. Cancer-associated VTE is one of the most important risk factors contributing to cancer mortality, making its prevention and treatment critical for patients with lung cancer.

Methods

We systematically searched for observational studies that estimated the prevalence of VTE in patients with lung cancer. A comprehensive search of electronic databases, including PubMed, EMBASE and Cochrane Library, was systematically conducted from database inception through January 21, 2022. The qualities of included studies were assessed in three domains, including patient selection, comparison, and results. Random effects meta-analyses of the prevalence of VTE in lung cancer were conducted using the metaprop procedure. Chi-square test and I 2 value were used to evaluate study heterogeneity.

Results

Thirty-five studies involving 742,156 patients were considered eligible for this study. The pooled prevalence of VTE among patients with lung cancer was 5% (95% CI: 0.043-0.056, P = 0.000). The regional prevalence of VTE was 7% (95% CI: 0.06-0.08; I2 = 99.2%) in North America, 8% (95% CI: 0.06-0.10; I2 = 97.6%) in Asia, 6% (95% CI: 0.04-0.09; I2 = 95.9%) in Europe and 11% (95% CI: 0.07-0.15) in Australasia.

Conclusions

The prevalence of lung cancer-related VTE is high and region-specific. These results of this review emphasize the importance of understanding the incidence of lung cancer-related VTE and provide argue for VTE screening of patients with lung cancer.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier PROSPERO (CRD42022306400).

Development and validation of a nomogram model for predicting venous thromboembolism risk in lung cancer patients treated with immune checkpoint inhibitors: A cohort study in China

OBJECTIVE

Venous thromboembolism (VTE) poses a significant threat to lung cancer patients, particularly those receiving treatment with immune checkpoint inhibitors (ICIs). We aimed to develop and validate a nomogram model for predicting the occurrence of VTE in lung cancer patients undergoing ICI therapy.

METHODS

The data for this retrospective cohort study was collected from cancer patients admitted to Chongqing University Cancer Hospital for ICI treatment between 2019 and 2022. The research data is divided into training and validation sets using a 7:3 ratio. Univariate and multivariate analyses were employed to identify risk factors for VTE. Based on these analyses, along with clinical expertise, a nomogram model was crafted. The model's predictive accuracy was assessed through receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis, clinical impact curve, and other relevant metrics.

RESULTS

The initial univariate analysis pinpointed 13 potential risk factors for VTE. The subsequent stepwise multivariate regression analysis identified age, Karnofsky performance status, chemotherapy, targeted, platelet count, lactate dehydrogenase, monoamine oxidase, D-dimer, fibrinogen, and white blood cell count as significant predictors of VTE. These 10 variables were the foundation for a predictive model, illustrated by a clear and intuitive nomogram. The model's discriminative ability was demonstrated by the ROC curve, which showed an area under the curve of 0.815 (95% CI 0.772-0.858) for the training set, and 0.753 (95% CI 0.672-0.835) for the validation set. The model's accuracy was further supported by Brier scores of 0.068 and 0.080 for the training and validation sets, respectively, indicating a strong correlation with actual outcomes.

CONCLUSION

We have successfully established and validated a nomogram model for predicting VTE risk in lung cancer patients treated with ICIs.

Role of recombinant human granulocyte colony-stimulating factor in development of cancer-associated venous thromboembolism in lung cancer patients who undergo chemotherapy

Background

The role of recombinant human granulocyte colony-stimulating factor (rhG-CSF), especially the long-acting factor in the development of cancer-associated venous thromboembolism (VTE) in lung cancer patients who undergo chemotherapy has been understudied, although the use of rhG-CSF has been reported to be associated with an increased risk of VTE.

Methods

We retrospectively reviewed 1,673 lung cancer patients who underwent hospitalized chemotherapy. We performed propensity score matching to offset confounding factors related to cancer-associated VTE development and classified the patients into short-acting (N = 273), long-acting (N = 273), and no rhG-CSF (N = 273) groups. The primary outcome was cumulative cancer-associated VTE development three months after all cycles of chemotherapy.

Results

The overall VTE incidence in the short-acting, long-acting, and no rhG-CSF groups was 5.5%, 10.3%, and 2.2%, respectively (P <0.001). The VTE incidence in the long-acting rhG-CSF group was higher than that in the short-acting (P = 0.039) and no rhG-CSF groups (P <0.001). The VTE incidence in the short-acting rhG-CSF group was higher than that in the no rhG-CSF group (P = 0.045). The use of rhG-CSF (hazard ratio [HR] 2.337; 95% confidence interval [CI] [1.236-5.251], P = 0.006) was positively correlated with VTE development among all patients, whereas the use of long-acting rhG-CSF (HR 1.917, 95% CI [1.138-4.359]; P = 0.016), was positively correlated with VTE development in patients receiving rhG-CSF.

Conclusion

The use of rhG-CSF, especially long-acting rhG-CSF, increases the risk of cancer-associated VTE development compared to no rhG-CSF use in lung cancer patients who undergo hospitalized chemotherapy.

Fibrin Clot Properties in Cancer: Impact on Cancer-Associated Thrombosis

Cancer is associated with a high risk of venous thromboembolism (VTE) and its recurrence. There is evidence that the prothrombotic fibrin clot phenotype, involving the formation of denser and stiffer clots relatively resistant to lysis, occurs in cancer patients, which is in part related to enhanced inflammation, oxidative stress, and coagulation activation, along with the release of neutrophil extracellular traps, indicating that fibrin-related mechanisms might contribute to cancer-associated thrombosis (CAT). Multiple myeloma and its therapy have been most widely explored in terms of altered fibrin characteristics, but prothrombotic fibrin clot features have also been reported in patients with active solid cancer, including lung cancer and gastrointestinal cancer. Patient-related factors such as advanced age, smoking, and comorbidities might also affect fibrin clot characteristics and the risk of CAT. Prothrombotic fibrin clot features have been shown to predict the detection of cancer in patients following VTE during follow-up. Cancer-specific therapies and anticoagulation can favorably modify the phenotype of a fibrin clot, which may alter the course of CAT. It is unclear whether the fibrin clot phenotype might help identify patients with CAT who are more likely to experience recurrent events. This narrative review summarizes the current knowledge on the role of fibrin clot structure and function in cancer patients in the context of CAT.

Lung Cancer Related Thrombosis (LCART): Focus on Immune Checkpoint Blockade

Cancer-associated thrombosis (CAT) is a common complication in lung cancer patients. Lung cancer confers an increased risk of thrombosis compared to other solid malignancies across all stages of the disease. Newer treatment agents, including checkpoint immunotherapy and targeted agents, may further increase the risk of CAT. Different risk-assessment models, such as the Khorana Risk Score, and newer approaches that incorporate genetic risk factors have been used in lung cancer patients to evaluate the risk of thrombosis. The management of CAT is based on the results of large prospective trials, which show similar benefits to low-molecular-weight heparins (LMWHs) and direct oral anticoagulants (DOACs) in ambulatory patients. The anticoagulation agent and duration of therapy should be personalized according to lung cancer stage and histology, the presence of driver mutations and use of antineoplastic therapy, including recent curative lung surgery, chemotherapy or immunotherapy. Treatment options should be evaluated in the context of the COVID-19 pandemic, which has been shown to impact the thrombotic risk in cancer patients. This review focuses on the epidemiology, pathophysiology, risk factors, novel predictive scores and management of CAT in patients with active lung cancer, with a focus on immune checkpoint inhibitors.

Tumor-infiltrating platelets promote the growth of lung adenocarcinoma

PURPOSE

Platelets could promote tumor growth and metastasis. However, the role of platelets in different subtypes of non-small cell lung cancer (NSCLC) and platelet infiltration in local tumor tissue remain unclear.

METHODS

Initially, platelet infiltration in lung adenocarcinoma (ADC) and lung squamous cell carcinoma (SCC) was estimated by CD41 expression using immunohistochemistry. Subsequently, co-incubation of NSCLC cell lines and platelets was performed to compare the ability of binding platelets. Subcutaneous tumor models were established to assess the ability of platelets to promote tumor growth. Then, RNA-seq data of NSCLC was used to identify differentially expressed genes and enriched pathways. Lastly, a clinical cohort comprising of ADC and SCC patients as well as meta-analysis was analyzed to compare the difference of coagulation associated clinical parameters.

RESULTS

We found high platelet infiltration in ADC, especially of advanced disease and metastases, whereas few platelets were observed in SCC. Moreover, ADC cell lines exhibited strong ability of binding platelets compared with SCC cell lines. Platelets could also promote the growth of ADC cell lines in vivo. Furthermore, coagulation cascades and fibrinogen were upregulated in ADC. And chemical inhibition of GPIIb/IIIa-fibrinogen axis reduced the binding of ADC cells and platelets. ADC patients were also in a hypercoagulable state characterized by higher d-dimer level and shorter clotting time. Finally, meta-analysis identified a higher risk of venous thromboembolism (VTE) in ADC patients and low molecular weight heparin (LMWH) treatment was effective at reducing this risk.

CONCLUSIONS

This study identified the differences of platelet infiltration and coagulation between ADC and SCC patients, which may inform the development of anticoagulation therapies for NSCLC.

Prevalence of Thromboembolic Events in Patients With Non-Small Cell Lung Cancer and RET Fusions

This cohort study examines the incidence, risks, and characteristics of deep vein thrombosis, pulmonary embolism, arterial thrombosis, and stroke among patients with non–small cell lung cancer (NSCLC) and RET fusions.

Osimertinib for an Advanced NSCLC Patient with Two Common EGFR Mutations and a Concomitant MET Exon 14 Skipping Mutation: A Case Report

Background

Lung cancer remains the leading cause of cancer-related mortality. Studies have revealed that a combination of crizotinib and EGFR tyrosine kinase inhibitors (TKIs) could be an effective treatment option for patients with sensitizing EGFR mutations and de novo or acquired MET amplification. Until now, there have been few reports of the response in patients harboring three mutations.

Case Presentation

A patient was diagnosed with advanced lung adenocarcinoma harboring EGFR Del19, L858R mutation and METex14. She received osimertinib, and repeated imaging revealed further tumor progression. Sixty-six days later, combined treatment with osimertinib and crizotinib was initiated. Unfortunately, the patient succumbed to death at home after 17 days.

Conclusion

This report firstly provided a lung adenocarcinoma patient with two common EGFR mutations (Del19 and L858R) and METex14. Our case raises a reminder about the tolerance and safety of combination therapy, especially in older peoples.

Evaluating the effect of immune checkpoint inhibitors on venous thromboembolism in non-small cell lung cancer patients

OBJECTIVE

Currently, immune checkpoint inhibitors (ICIs) therapy is one of the main methods of treatment in non-small cell lung cancer (NSCLC). This study aimed to explore the risk factors of VTE and evaluate the effect of ICIs on VTE in patients with NSCLC.

RESEARCH DESIGN AND METHODS

We retrospectively studied patients with NSCLC who were divided into VTE group and without VTE (Non-VTE) group. We identified the risk factors of VTE in NSCLC patients and evaluated the effect of ICIs on VTE in NSCLC patients.

RESULTS

We found that clinical stage III-IV (P = 0.015) and Khorana score (KS) ≥ 2 (P = 0.047) were independent risk factors for the occurrence of VTE in NSCLC, and treatment with ICIs reduced the risk of VTE occurrence (P = 0.028). There were no differences of survival rates in the 12-month (P = 0.449), 24-month (P = 0.412), or 36-month (P = 0.315) between the VTE and non-VTE groups. History of anti-angiogenic therapy (P = 0.033) and chronic obstructive pulmonary disease (COPD) (P = 0.046) were independent risk factors for VTE in NSCLC patients who were treated with ICIs.

CONCLUSION

This study suggests that we should strengthen anticoagulant therapy when using ICIs for NSCLC patients with a history of anti-angiogenic therapy and COPD.

Stratification of Risk Factors of Lung Cancer-Associated Venous Thromboembolism and Determining the Critical Point for Preemptive Intervention: A Systematic Review With Meta-analysis

Background

Several biomarkers or risk factors have been identified and several prediction models exist. The major limitations inherent in these models include cost-ineffectiveness and lack of systematic stratification of risk factors resulting in the inclusion of clinically insignificant biomarkers in the models. This review aimed to systematically stratify the risk factors of lung cancer-associated venous thromboembolism (VTE) and determine the critical point for preemptive intervention.

Methods

This systematic review was structured as per the Preferred Reporting Item for Systematic Reviews and Meta-analyses. We searched MEDLINE, PubMed, Cochrane Library, CINAHL, Academic Search Complete, and PsycINFO from the onset to June 2022. We included studies that reported the risk factors of lung cancer-associated VTE and corresponding risk estimates, irrespective of treatment status but studies were excluded if patients were on anti-VTE medications. We employed random effects models of meta-analysis and computed risk stability index and risk weight (Rw) to achieve the review objectives. The review protocol is registered with PROSPERO (CRD42022336476).

Results

The clinically significant risk factors of VTE in lung cancer patients were D-dimer (odds ratio [OR] = 5.510, 95% CI = 2.6-11.7; Rw = 5.0), albumin (OR = 2.2, 95% CI = 1.0-4.8; Rw = 1.79), leukocyte (OR = 2.48, 95% CI = 1.9-3.2; Rw = 1.77), histological type (OR = 1.69 , 95% CI = 1.2-2.4; Rw = 1.3), age (OR = 1.56; Rw = 0.99), and hemoglobin (OR = 1.85, 95% CI = 1.3-2.6; Rw = 0.92). Based on the distribution of Rw across risk factors, the critical point (upper third of the upper quartile class) was 4.5 and may mark the point at which preemptive intervention should be commenced.

Conclusions

Targeted screening for VTE in lung cancer patients could be patient-specific and should be based on a combination of the most significant risk factors required to meet the critical point, provided that such a combination is affordable as illustrated in the ALBAH model.

Registration

The review protocol is registered with PROSPERO (ID: CRD42022336476).

Management of venous thromboembolism in patients with lung cancer: a state-of-the-art review

Venous thromboembolism (VTE) is common and life-threatening in patients with lung cancer. Management of VTE is critical for patients with lung cancer. Risk assessment, thromboprophylaxis and treatment of VTE constitute the core issues of VTE management in patients with lung cancer. Although its overall principles should follow recommendations in authoritative guidelines, VTE management in patients with lung cancer may be slightly special in some specific aspects. Despite the extensive validation of Khorana score for patients with all cancer types, its value in VTE risk assessment of patients with lung cancer is controversial. It is important to determine the VTE risk assessment score that can accurately and specifically assess the VTE risk of patients with lung cancer. Clinical practice patterns of thromboprophylaxis may vary by cancer types, since different sites of cancer may have different levels of VTE risk. To understand the thromboprophylaxis specific for lung cancer is of vital importance for patients with lung cancer. Although it is essential to comply with authoritative guidelines, the duration and timing of initiation of thromboprophylaxis in surgical patients with lung cancer may need further study. Taken together, the purpose of this review is to provide an overview of state-of-the-art VTE stewardship specific for patients with lung cancer.

Resveratrol Affects Sphingolipid Metabolism in A549 Lung Adenocarcinoma Cells

Resveratrol is a naturally occurring polyphenol which has various beneficial effects, such as anti-inflammatory, anti-tumor, anti-aging, antioxidant, and neuroprotective effects, among others. The anti-cancer activity of resveratrol has been related to alterations in sphingolipid metabolism. We analyzed the effect of resveratrol on the enzymes responsible for accumulation of the two sphingolipids with highest functional activity—apoptosis promoting ceramide (CER) and proliferation-stimulating sphingosine-1-phosphate (S1P)—in human lung adenocarcinoma A549 cells. Resveratrol treatment induced an increase in CER and sphingosine (SPH) and a decrease in sphingomyelin (SM) and S1P. Our results showed that the most common mode of CER accumulation, through sphingomyelinase-induced hydrolysis of SM, was not responsible for a CER increase despite the reduction in SM in A549 plasma membranes. However, both the activity and the expression of CER synthase 6 were upregulated in resveratrol-treated cells, implying that CER was accumulated as a result of stimulated de novo synthesis. Furthermore, the enzyme responsible for CER hydrolysis, alkaline ceramidase, was not altered, suggesting that it was not related to changes in the CER level. The enzyme maintaining the balance between apoptosis and proliferation, sphingosine kinase 1 (SK1), was downregulated, and its expression was reduced, resulting in a decrease in S1P levels in resveratrol-treated lung adenocarcinoma cells. In addition, incubation of resveratrol-treated A549 cells with the SK1 inhibitors DMS and fingolimod additionally downregulated SK1 without affecting its expression. The present studies provide information concerning the biochemical processes underlying the influence of resveratrol on sphingolipid metabolism in A549 lung cancer cells and reveal possibilities for combined use of polyphenols with specific anti-proliferative agents that could serve as the basis for the development of complex therapeutic strategies.

Solanum Procumbens-Derived Zinc Oxide Nanoparticles Suppress Lung Cancer In Vitro through Elevation of ROS

Lung cancer is one of the cancers with high mortality rate. The current therapeutic regimens have only limited success rate. The current work highlights the potential of Solanum procumbens-derived zinc oxide nanoparticle (SP-ZnONP)-induced apoptosis in A549 lung cancer cells. Synthesized nanoparticles were confirmed by UV-Vis spectrophotometry, X-ray diffraction (XRD), dynamic light scattering analysis (DLS), scanning electron microscopy (SEM), Fourier transform infrared (FT-IR), and photoluminescence analysis. Lactate dehydrogenase (LDH), cytotoxicity, and cell viability assays revealed that the SP-ZnONP caused the cell death and the inhibition concentration (IC₅₀) was calculated to be 61.28 μg/mL. Treatment with SP-ZnONPs caused morphological alterations in cells, such as rounding, which may have been caused by the substance's impact on integrins. Acridine orange/ethidium bromide dual staining revealed that the cells undergo apoptosis in a dose-dependent manner, which indicates the cell death. Furthermore, reactive oxygen species (ROS) were examined and it was shown that the nanoparticles elevated ROS levels, which led to lipid peroxidation. In short, the SP-ZnONPs increase the level of ROS, which in turn causes lipid peroxidation results in apoptosis. On the other hand, the SP-ZnONPs decrease nitric oxide level in A549 cells in a dose-dependent manner, which also supports the apoptosis. In conclusion, SP-ZnONPs would become a promising treatment option for lung cancer.

One-Year Incidences of Venous Thromboembolism, Bleeding, and Death in Patients With Lung Cancer (Cancer-VTE Subanalysis)

Introduction

This subanalysis aimed to provide real-world data on venous thromboembolism (VTE) from patients with lung cancer in the Cancer-VTE Registry.

Methods

The primary outcome was the number of baseline VTE events in patients with lung cancer. The 1-year cumulative incidences of symptomatic VTE; composite VTE (symptomatic and incidental VTE requiring treatment); bleeding; cerebral infarction, transient ischemic attack, and systemic embolic events; and all-cause death were calculated. Clinical trial registration: UMIN000024942.

Results

The study enrolled a total of 2377 patients with lung cancer; of these, 119 (5.0%) had VTE (six [0.3%], symptomatic, and 113 [4.8%], asymptomatic) and 14 (0.6%) had pulmonary embolism at baseline. During the follow-up period (mean, 337.7 d), the incidence was 0.6% for symptomatic VTE, 1.8% for composite VTE, 1.5% for bleeding events, 1.3% for cerebral infarction, transient ischemic attack, and systemic embolism, and 19.1% for all-cause death. Composite VTE frequency did not vary by anticancer drug type. Patients with (versus without) VTE at baseline had higher hazard ratios (HRs) for composite VTE (unadjusted HR: 5.29; Gray test p < 0.001) and symptomatic VTE (unadjusted HR: 4.89; Gray test p = 0.007). Patients with VTE at baseline had higher HRs for bleeding events (unadjusted HR: 3.27; Gray test p = 0.010) and all-cause death (unadjusted HR: 2.73; log-rank test p < 0.001) than patients without. In multivariable analysis, patients with baseline VTE prevalence and Eastern Cooperative Oncology Group Performance Status of 2 had increased composite VTE risk during cancer therapy. There were no other risk factors for composite VTE.

Conclusions

Our findings emphasize the importance of VTE screening at cancer diagnosis.

Cancer Histology and Natural History of Patients with Lung Cancer and Venous Thromboembolism

Simple Summary

Cancer is a widely heterogeneous disease, and the natural history of patients with cancer-associated thrombosis may differ according to the cancer site. Lung cancer is the most common malignancy, and a leading cause of death. A number of studies in the literature suggest that patients with adenocarcinoma may have a worse outcome than those with squamous or other types of lung cancer. The aim of the current study was to assess the potential impact of lung cancer histology on the incidence rates of VTE recurrences, major bleeding, or death appearing during the course of anticoagulation, in patients with lung cancer and VTE. Our findings, obtained from a large series of consecutive patients with lung cancer and VTE (482 patients), reveal important differences between patients with adenocarcinoma vs. other histologies in their outcomes during anticoagulation. This might likely help to design better therapeutic strategies for patients with lung cancer.

Abstract

Background: In patients with lung cancer and venous thromboembolism (VTE), the influence of cancer histology on outcome has not been consistently evaluated. Methods: We used the RIETE registry (Registro Informatizado Enfermedad TromboEmbólica) to compare the clinical characteristics and outcomes during anticoagulation in patients with lung cancer and VTE, according to the histology of lung cancer. Results: As of April 2022, there were 482 patients with lung cancer and VTE: adenocarcinoma 293 (61%), squamous 98 (20%), small-cell 44 (9.1%), other 47 (9.8%). The index VTE was diagnosed later in patients with squamous cancer than in those with adenocarcinoma (median, 5 vs. 2 months). In 50% of patients with adenocarcinoma, the VTE appeared within the first 90 days since cancer diagnosis. During anticoagulation (median 106 days, IQR: 45–214), 14 patients developed VTE recurrences, 15 suffered major bleeding, and 218 died: fatal pulmonary embolism 10, fatal bleeding 2. The rate of VTE recurrences was higher than the rate of major bleeding in patients with adenocarcinoma (11 vs. 6 events), and lower in those with other cancer types (3 vs. 9 events). On multivariable analysis, patients with adenocarcinoma had a non-significantly higher risk for VTE recurrences (hazard ratio [HR]: 3.79; 95%CI: 0.76–18.8), a lower risk of major bleeding (HR: 0.29; 95%CI: 0.09–0.95), and a similar risk of mortality (HR: 1.02; 95%CI: 0.76–1.36) than patients with other types of lung cancer. Conclusions: In patients with lung adenocarcinoma, the rate of VTE recurrences outweighed the rate of major bleeding. In patients with other lung cancers, it was the opposite.

Incidence of venous thromboembolism in advanced lung cancer and efficacy and safety of direct oral anticoagulants: a multicenter, prospective, observational study (Rising-VTE/NEJ037 study)

Background:

Venous thromboembolism (VTE) is a well-known type of cancer-associated thrombosis and a common complication of malignancy. However, the incidence of VTE associated with lung cancer and the effectiveness of direct oral anticoagulants remain unclear. This study aimed to identify the incidence of VTE associated with lung cancer at the time of diagnosis or during treatment, the efficacy and safety of edoxaban, and associated risk factors.

Methods:

The Rising-VTE/NEJ037 study was a multicenter prospective observational study. Altogether, 1021 patients with lung cancer who were unsuitable for radical resection or radiation were enrolled and followed up for 2 years. Patients with VTE at the time of lung cancer diagnosis started treatment with edoxaban. The primary endpoint of this trial was the rate of newly diagnosed VTE after enrollment or recurrence rate 6 months after treatment initiation.

Results:

Data were available for 1008 patients. The median age was 70 years (range: 30–94 years), and 70.8% were men. Sixty-two patients had VTE at the time of lung cancer diagnosis, and 38 (9.9%) developed VTE at follow-up. No cases of VTE recurrence were recorded 6 months after treatment initiation with edoxaban. Major and clinically relevant non-major bleeding events occurred in 4.9% of patients and increased to 22.7% in the edoxaban treatment group.

Conclusions:

VTE occurrence should be monitored during lung cancer treatment. Although treatment with edoxaban was highly effective in preventing VTE recurrence, its administration should be cautiously considered because of the high bleeding rate.

Trial registration:

jRCTs061180025.

Can thromboprophylaxis build a link for cancer patients undergoing surgical and/or chemotherapy treatment? The MeTHOS cohort study

BACKGROUND

Patients with active cancer have a 4-sevenfold increased risk for venous thromboembolism (VTE) especially during systematic anticancer treatment. Simultaneously, surgery is an additional risk factor.

METHODS

The Metaxas's Hospital THromboprophylaxis program in Oncological & Surgical Patients (MeTHOS) is a prospective, phase IV, observational, non-interventional cohort study, aiming to record the thromboprophylaxis practice patterns in high-risk active cancer patients undergoing surgical and/or chemotherapy treatment.

RESULTS

We are reporting results from 291 ambulatory patients (median age: 67 years, Q1-Q3: 59-73 years, 54.6% males) who received anti-neoplastic treatment and administered thromboprophylaxis. 59.8% had cardiovascular disease (mostly hypertension), 76.6% were reported as having at least one comorbidity, while 27.5% and 15.8% accumulated two and three comorbidities, respectively. 94.9% of the patients were receiving highly thrombogenic agents such as platinum-based agents, 5-FU, immunotherapy, antiangiogenics/anti-VEGF, or erythropoietin. 26.5% of the patients were initially surgically treated. In terms of anticoagulation, all patients were treated with tinzaparin (fixed dose, 10,000 Anti-Xa IU, OD). The median anticoagulation duration was 6.2 months. Six thrombotic events were observed (2.06%, 95% CI: 0.76-4.43%): 5 were DVT, and one PE. With respect to safety, 7 bleeding events occurred (2.6%, 95% CI: 1.0-5.3%); 6 of them were minor.

CONCLUSIONS

Thromboprophylaxis with LMWH in patients with active cancer and high thrombotic burden was safe and effective. Intermediate dose of tinzaparin seems to be an appropriate agent for cancer-associated thromboprophylaxis management.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT04248348.

Incidence of venous thromboembolism and discriminating capacity of Khorana score in lung cancer patients treated with immune checkpoint inhibitors

Venous-thromboembolism (VTE) is increased in lung cancer patients (LCP) treated with immune-checkpoint inhibitors (ICIs) but risk factors are not identified and the Khorana Score (KS) is not validated. To assess VTE incidence and its clinical impact, to investigate potential clinical risk factors and KS performance in LCP. Retrospective analysis of LCP initiating ICIs treatment between June 2015 and November 2020 in a for-profit cancer center. 481 patients were included: 62% adenocarcinoma, 70% PDL1 + , 86% stage-IV-disease. Over a median follow-up of 9.8 months, 47 VTE were observed: 28 pulmonary embolisms, 15 deep venous thromboses (distal n = 9, proximal n = 6), 3 inferior vena cava thromboses, 1 other VTE, no superficial or digestive vein thrombosis. Median time from ICIs' initiation to VTE was 180 (11-1277) days. Overall survival was significantly lower in patients who experienced VTE (42.5 vs. 86.8 months, p = 0.006). In univariate analysis patients VTE was more frequent in metastatic patients (11.1% vs. 1.5%, p = 0.015) and lower in those treated with durvalumab (1.9% vs. 9.6%, p = 0.046). Logistic regression analysis showed that non-metastatic status (OR 0.13; 0.02-0.95, p = 0.04) and BMI (OR 1.07; 1.01-1.14, p = 0.028) were associated with VTE. The rate of VTE was the same in patients with a KS < or ≥ 2 (10.2% vs. 9.3%, p = 0.87). ICIs-treated LCP are at high risk of thromboembolism. VTE has a negative impact on survival. KS does not perform well in LCP. It is important to identify which VTE prediction models are available to be used in adult ambulatory lung cancer patients.

Feasibility and impact of screening for venous thromboembolism in treatment-naive lung cancer patients-Results of a prospective cohort study

BACKGROUND

Venous thromboembolism (VTE) in cancer remains underdiagnosed. This prospective study aimed to evaluate the feasibility of screening for VTE in lung cancer (LC) patients. We assess the incidence of VTE, its risk factors, and effects on overall survival (OS).

METHODS

Consecutive treatment-naive LC patients were screened for deep venous thrombosis (DVT) with compression ultrasonography and pulmonary thromboembolism (PTE) with computed tomography pulmonary angiography (CTPA) at diagnosis and after 3 months of treatment. The incidence rate of VTE (DVT and/or PTE) was calculated. Risk factors associated with VTE were assessed using logistic regression analysis. All participants were followed-up to 1 year after enrollment. OS was compared in LC subjects with and without VTE, using the Cox proportional hazard analysis.

RESULTS

Around 301 subjects with LC (stages IIIB-IV accounted for 83.1%) were enrolled, of which 16 had VTE (5.3%). The incidence rate of VTE was 90 per 1000 person-years (PY). PTE was asymptomatic in 27.3% of cases while all DVT episodes were symptomatic. The incidence rate of asymptomatic PTE identified during the screening was 17 per 1000 PY. The median duration from LC diagnosis to the VTE event was 96.5 days. Median OS was significantly less in VTE patients [161 versus 311 days; P = 0.007] and death was attributable to VTE in 50%. After adjusting for covariates, VTE (hazard ratio [HR] = 2.1), smoking (HR = 1.7), and Eastern cooperative oncology group performance status ≥2 (HR = 1.6) were independently associated with poor OS in LC.

CONCLUSIONS

VTE occurs in approximately 1 in 20 newly-diagnosed patients with LC and is associated with decreased OS. Screening for PTE may be considered even in resource-limited settings.

Advances in the Prediction and Risk Assessment of Lung Cancer-Associated Venous Thromboembolism

According to the most recent data from the National Cancer Center, venous thromboembolism (VTE) has unsurprisingly become one of the most common complications in lung cancer. VTE not only interferes with the equilibrium of the clotting system but it also affects tumor progression and prognosis. For the identification of high-risk patients, many clinical risk assessment models have been developed and validated based on the risk factors found in previous studies. In this review, we will summarize advances in prediction and risk assessment of VTE, with a focus on early diagnosis and therapy, reduction of mortality, and the burden of medical costs in lung cancer patients.

Venous thromboembolism incidence and risk factors in non-small cell lung cancer patients receiving first-line systemic therapy

BACKGROUND

There are limited data on venous thromboembolism (VTE) incidence and predictive factors in non-small cell lung cancer (NSCLC) across first-line therapies.

OBJECTIVE

To evaluate VTE incidence rates and identify predictive factors in NSCLC patients receiving first-line systemic therapies, including immune checkpoint inhibitors (ICIs).

PATIENTS/METHODS

This is a single institution retrospective study of adult NSCLC patients who received first-line treatment, including chemotherapy, ICIs (pembrolizumab, nivolumab, atezolizumab, avelumab, and durvalumab), and/or targeted therapies (TTs) (erlotinib, gefitinib, afatinib, osimertinib, crizotinib, alectinib, ceritinib). Risk factors included Khorana score, cancer stage, central venous catheter, pacemaker, comorbidities, and prior VTE. The primary objective - cumulative incidence of VTE at 6- and 12-months by treatment group - was compared using Gray's test. Univariable and multivariable competing risk analyses were used to identify predictors.

RESULTS

Of 1587 evaluable patients, 53% were male, 79% white, 18% black, median age was 66; 58% had adenocarcinoma, 32% squamous cell carcinoma, and 47% metastatic disease; 1043 received chemotherapy, 171 ICIs, 157 chemotherapy plus concomitant ICI, 107 chemotherapy and durvalumab maintenance, and 109 TTs. The 6-month cumulative incidence of VTE by treatment type was 5.0%, 7.6%, 9.9%, 9.4%, and 11.1%; 12-month incidence was 6.5%, 9.0%, 12.8%, 12.2%, and 13.1% per arm, respectively (p = 0.01). Treatment type (p = 0.034) and nicotine dependence (p = 0.048) were significantly associated with time to VTE in multivariable analyses.

CONCLUSION

Treatment type and smoking status were predictive of time to VTE in NSCLC patients receiving various first-line therapies. Cumulative incidence was highest in those receiving TTs and combination chemotherapy plus ICI.

Development and validation of a predictive score for venous thromboembolism in newly diagnosed non-small cell lung cancer

INTRODUCTION

The risk of venous thromboembolism (VTE) varies among tumour types, and different cancer type-specific risks for VTE prediction remain undefined. We aimed to establish a prediction model for non-small lung cancer (NSCLC)-associated VTE.

MATERIALS AND METHODS

We analysed data from a prospective cohort of patients with newly diagnosed NSCLC. We then developed a VTE risk prediction model using data of patients who were recruited from 2013 to 2017 (n = 602, development cohort) and validated this model using date of patients recruited from 2018 to 2019 (n = 412, validation cohort). The cumulative 6 months VTE incidence observed in both cohorts was calculated.

RESULTS

The parameters in this new model included Eastern Cooperative Oncology Group (ECOG) performance status ≥2 (1 point), EGFR mutation (-1 point), neutrophil count ≥7.5 × 10⁹/L (2 points), hemoglobin <115 g/L (1 point), CEA ≥5.0 ng/mL (2 points), and D-dimer level ≥1400 ng/mL (4 points). The cross-validated concordance indices of the model in the development and validation cohorts were 0.779 and 0.853, respectively. Furthermore, the areas under the curve in the two cohorts were 0.7563 (95% confidence interval [CI]: 0.6856-0.8129, P < 0.001) and 0.8211 (95% CI: 0.7451-0.8765, P < 0.001) for development and validation cohorts, respectively.

CONCLUSIONS

The new VTE risk prediction model incorporated patient characteristics, laboratory values, and oncogenic status, and was able to stratify patients at high risk of VTE in newly diagnosed NSCLC within 6 months of diagnosis.

Increased activity of procoagulant factors in patients with small cell lung cancer

Small cell lung cancer (SCLC) patients have augmented risk of developing venous thromboembolism, but the mechanisms triggering this burden on the coagulation system remain to be understood. Recently, cell-derived microparticles carrying procoagulant phospholipids (PPL) and tissue factor (TF) in their membrane have attracted attention as possible contributors to the thrombogenic processes in cancers. The aims of this study were to assess the coagulation activity of platelet-poor plasma from 38 SCLC patients and to provide a detailed procoagulant profiling of small and large extracellular vesicles (EVs) isolated from these patients at the time of diagnosis, during and after treatment compared to 20 healthy controls. Hypercoagulability testing was performed by thrombin generation (TG), procoagulant phospholipid (PPL), TF activity, Protein C, FVIII activity and cell-free deoxyribonucleic acid (cfDNA), a surrogate measure for neutrophil extracellular traps (NETs). Our results revealed a coagulation activity that is significantly increased in the plasma of SCLC patients when compared to age-related healthy controls, but no substantial changes in coagulation activity during treatment and at follow-up. Although EVs in the patients revealed an increased PPL and TF activity compared with the controls, the TG profiles of EVs added to a standard plasma were similar for patients and controls. Finally, we found no differences in the coagulation profile of patients who developed VTE to those who did not, i.e. the tests could not predict VTE. In conclusion, we found that SCLC patients display an overall increased coagulation activity at time of diagnosis and during the disease, which may contribute to their higher risk of VTE.

High discrepancy in thrombotic events in non-small cell lung cancer patients with different genomic alterations

Background

Acute complications, such as venous thromboembolism (VTE), are common in patients with advanced severe lung cancers. However, current VTE risk scores cannot adequately identify high-risk patients with non-small cell lung cancer (NSCLC). The study proposed to elucidated the incidence of thromboembolism (TE) in patients with different oncogenic aberrations and the impact of these aberrations on the efficacy of targeted therapy in patients with NSCLC.

Methods

A systemic review was conducted in Web of Science, PubMed, Embase and the Cochrane Library to evaluate the incidence of TE in different molecular subtypes of NSCLC. Data from patients diagnosed of advanced NSCLC who harboring anaplastic lymphoma kinase (ALK) or ROS proto-oncogene 1 receptor tyrosine kinase (ROS1) rearrangements since 2016 to 2019 were also retrospectively collected. A meta-analysis with random-effects model, sensitivity analysis and publication bias were performed. The principal summary measure was incidence of thrombotic events in NSCLC patients. And the efficacy of tyrosine kinase inhibitor (TKI) therapy was compared between the two subgroups.

Results

A total of 5,767 cases from 20 studies were included in the analysis of the incidence of thrombosis in patients with different oncogenic alterations. The pooled analysis showed a higher risk of thrombosis in ROS1-fusion types (41%, 95% CI: 35-47%) and ALK-fusion types (30%, 95% CI: 24-37%) than in EGFR-mutation (12%, 95% CI: 8-17%), KRAS-mutation (25%, 95% CI: 13-50%), and wild-type (14%, 95% CI: 10-20%) cases. A high prevalence of thrombosis (ALK: 24.4%; ROS1: 32.6%) was observed in the Shanghai Pulmonary Hospital (SPH) cohort of 224 patients with ALK or ROS1 fusion. Furthermore, patients with embolism had significantly shorter progression-free survival (PFS) after TKI therapy than those without embolism, both in the ALK+ cohort (5.6 vs. 12.9 months, P<0.0001) and in the ROS1+ cohort (9.6 vs. 17.6 months, P=0.0481).

Conclusions

NSCLC patients with ALK/ROS1 rearrangements are more likely to develop thrombosis than patients with other oncogenic alterations. Thrombosis may also be associated with an inferior response and PFS after TKI therapy.

Analysis on risk factors of lung cancer complicated with pulmonary embolism

INTRODUCTION

Pulmonary embolism (PE) is a potentially fatal complication and its morbidity together with fatalness will further increase when in patients with malignant tumors. Fast and accurate early diagnosis of PE thus seems considerably important.

OBJECTIVE

To explore the risk factors of lung cancer complicated with PE.

MATERIALS AND METHODS

A retrospective cohort study consisted of 40 lung cancer patients with PE (PE group) and 60 lung cancer patients without PE (non-PE group) were analyzed.

RESULTS

The white blood cell (WBC) count, D-dimer and low-density lipoprotein (LDL) were higher in PE group than those in non-PE group (P < 0.05), whereas the arterial partial pressure of oxygen (PaO₂ ) in PE group was lower than that in non-PE group (P < 0.05). Carcinoembryonic antigen (CEA) level between two groups also exhibited statistical difference (P < 0.05). Those lung adenocarcinoma patients with stages III and IV tumor, coupled with deep venous thrombosis (DVT), having experienced bevacizumab treatment or platinum-based chemotherapy more likely suffered from PE (P < 0.05). The multivariate analysis revealed that high D-dimer, chemotherapy, DVT, stages III to IV, adenocarcinoma were independent risk factors associated with PE (P < 0.05). The overall survival time of patients in case group was significantly shorter than that in the control group with a median survival duration being 10.5 months (95%CI, 8.95-12.05) and 16.8 months (95%CI, 14.62-18.98), respectively, (P < 0.01).

CONCLUSIONS

High D-dimer, chemotherapy, DVT, stages III to IV and adenocarcinoma might have a positive correlation with PE, meanwhile, PE always predicted a poor prognosis in lung cancer patients.

The risk of venous thromboembolism after surgery for esophagogastric malignancy and the impact of chemotherapy: a population-based cohort study

To define the incidence of postoperative venous thromboembolism (VTE) and effects of chemotherapy in a population undergoing surgery for esophagogastric cancer. This population-based cohort study used linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care data from England to identify subjects undergoing esophageal or gastric cancer surgery between 1997 and 2014. Exposures included age, comorbidity, smoking, body mass index, and chemotherapy. Crude rates and adjusted hazard ratios (HRs) were calculated for rate of first postoperative VTE using Cox regression models. The cumulative incidence of VTE at 1 and 6 months was estimated accounting for the competing risk of death from any cause. Of the 2,452 patients identified, 1,012 underwent gastrectomy (41.3%) and 1,440 esophagectomy (58.7%). Risk of VTE was highest in the first month, with absolute VTE rates of 114 per 1,000 person-years (95% CI 59.32-219.10) following gastrectomy and 172.73 per 1,000 person-years (95% CI 111.44-267.74) following esophagectomy. Neoadjuvant and adjuvant chemotherapy was associated with a six-fold increased risk of VTE following gastrectomy, HR 6.19 (95% CI 2.49-15.38). Cumulative incidence estimates of VTE at 6 months following gastrectomy in patients receiving no chemotherapy was 1.90% and esophagectomy 2.21%. However, in those receiving both neoadjuvant and adjuvant chemotherapy, cumulative incidence following gastrectomy was 10.47% and esophagectomy, 3.9%. VTE rates are especially high in the first month following surgery for esophageal and gastric cancer. The cumulative incidence of VTE at 6 months is highest in patients treated with chemotherapy. In this category of patients, targeted VTE prophylaxis may prove beneficial during chemotherapy treatment.

Could venous thromboembolism and major bleeding be indicators of lung cancer mortality? A nationwide database study

Background

Venous thromboembolism (VTE) is highly prevalent in cancer patients and can cause severe morbidity. VTE treatment is essential, but anticoagulation increases the risk of major bleeding. The purpose was to evaluate the impact of VTE and major bleeding on survival and to identify significant risk factors for these events in lung cancer patients.

Methods

Data were extracted from a permanent sample of the French national health information system (including hospital and out-of-hospital care) from 2009 to 2016. All episodes of VTE and major bleeding events within one year after cancer diagnosis were identified. A Cox model was used to analyse the effect of VTE and major bleeding on the patients’ one-year survival. VTE and major bleeding risk factors were analysed with a Fine and Gray survival model.

Results

Among the 2553 included patients with lung cancer, 208 (8%) had a VTE episode in the year following diagnosis and 341 (13%) had major bleeding. Almost half of the patients died during follow-up. Fifty-six (60%) of the patients presenting with pulmonary embolism (PE) died, 48 (42%) of the patients presenting with deep vein thrombosis (DVT) alone died and 186 (55%) of those presenting with a major bleeding event died. The risk of death was significantly increased following PE and major bleeding events. VTE concomitant with cancer diagnosis was associated with an increased risk of VTE recurrence beyond 6 months after the first VTE event (sHR = 4.07 95% CI: 1.57–10.52). Most major bleeding events did not appear to be related to treatment.

Conclusion

VTE is frequent after a diagnosis of lung cancer, but so are major bleeding events. Both PE and major bleeding are associated with an increased risk of death and could be indicators of lung cancer mortality.

Expanding Access to Lung Cancer Clinical Trials by Reducing the Use of Restrictive Exclusion Criteria: Perspectives of a Multistakeholder Working Group

Low rates of adult patient participation have been a persistent problem in cancer clinical trials and have continued to be a barrier to efficient drug development. The routine use of significant exclusion criteria has contributed to this problem by limiting participation in studies and creating significant clinical differences between the study cohorts and the real-world cancer patient populations. These routine exclusions also unnecessarily restrict opportunities for many patients to access potentially promising new therapies during clinical development. Multiple efforts are underway to broaden eligibility criteria, allowing more patients to enroll in studies and generating more robust data regarding the effect of novel therapies in the population at large. Focusing specifically on lung cancer as an example, a multistakeholder working group empaneled by the LUNGevity Foundation identified 14 restrictive and potentially outdated exclusion criteria that appear frequently in lung cancer clinical trials. As a part of the project, the group evaluated data from multiple recent lung cancer studies to ascertain the extent to which these 14 criteria appeared in study protocols and played a role in excluding patients (screen failures). The present report describes the working group's efforts to limit the use of these routine exclusions and presents clinical justifications for reducing the use of 14 criteria as routine exclusions in lung cancer studies, potentially expanding trial eligibility and improving the generalizability of the results from lung cancer trials.

Venous Thromboembolism in Patents With Lung Cancer

Lung cancer is the leading cause of death from cancer in Japan. Studies in other countries have reported a venous thromboembolism (VTE) rate of 4%-20% in cancer patients. In this study, we aimed to determine the incidence of VTE in lung cancer patients in Japan and compared the characteristics of patients with and without VTE. In this retrospective cohort study, the clinicopathological characteristics of study patients with and without concomitant VTE were compared. Patients with lung cancer treated at Fukui Prefectural Hospital, Japan from 2008 to 2017. Of the 1471 patients with lung cancer studied, 28 developed VTE. Five patients developed pulmonary thromboembolism (PTE) alone, 9 PTE with concomitant deep vein thrombosis, and 14 deep vein thrombosis alone. Compared with patients in the non-VTE group, the VTE group was significantly younger (mean value ± SD 66.3 ± 10.1 vs. 73.0 ± 10.6 years, p = 0.001), contained significantly more patients with stage IIIb-IV disease (p = 0.002), and had a significantly higher rate of chemotherapy (p < 0.001) and radiation therapy (p = 0.007). There was no significant difference in median survival time from lung cancer diagnosis between the VTE and non-VTE groups. The 1-year mortality rate after VTE diagnosis was 60.7%. Lung cancer was the most frequent cause of death, followed by infection and VTE. Several baseline characteristics differed between patients with and without VTE. The prognosis may worsen after development of VTE, suggesting that lung cancer patients should be carefully monitored for it.

Association of ALK rearrangement and risk of venous thromboembolism in patients with non-small cell lung cancer: A prospective cohort study

BACKGROUND

Isolated reports are inconsistent regarding the risk of venous thromboembolism (VTE) in patients with anaplastic lymphoma kinase (ALK) rearranged non-small cell lung cancer (NSCLC). This study examined whether ALK rearrangement could have an influence on VTE in a prospective cohort.

METHODS

In a cohort of 836 consecutive patients with NSCLC, patients with epidermal growth factor receptor (EGFR) or kitten rat sarcoma (KRAS) mutations were ruled out for VTE interference. Finally, 341 qualified patients were observed. The median follow up period is 7.5 months (3.1-15.4m). ALK rearrangement was detected by fluorescence in situ hybridization at baseline.

RESULTS

Overall VTE events occurred in 37 (10.9%) of 341 patients. In multivariable analysis including age, sex, tumor histology, tumor stage, performance status, and ALK status, ALK rearrangement (sub-distribution hazard radio 2.47, 95% confidence interval 1.04-5.90) was associated with the increased risk of VTE. The cumulative incidence of VTE was 26.9% and 9.2% in the patients with and without ALK rearrangement after 6 months. After 1 year the corresponding cumulative incidence was 26.9% and 9.7% respectively (Gray test P = .005).

CONCLUSIONS

The presence of ALK rearrangement is associated with increased risk of VTE in patients with NSCLC.

Definitions, adjudication, and reporting of pulmonary embolism-related death in clinical studies: A systematic review

BACKGROUND

Pulmonary embolism (PE)-related death is a component of the primary outcome in many venous thromboembolism (VTE) studies. The absence of a standardized definition for PE-related death hampers study outcome evaluation and between-study comparisons.

OBJECTIVES

To summarize definitions for PE-related death used in recent VTE studies and to assess the PE-related death rate.

PATIENTS/METHODS

A systematic literature search was conducted on 26 April 2018 from 1 January 2014 up to the search date in MEDLINE, Embase, and CENTRAL. Cohort studies and randomized trials in which PE-related death was included in the primary outcome were eligible. Screening of titles, abstracts, and full-text articles, and data extraction were independently performed in duplicate by two authors. Study outcomes included the definition for PE-related death, VTE case-fatality rate, and death due to PE rate. Descriptive statistics were used to analyze the data.

RESULTS

Of the 6807 identified citations, 83 studies were included of which 27% were randomized trials, 31% were prospective, and 42% retrospective cohort studies. Thirty-five studies (42%) had a central adjudication committee. Thirty-eight (46%) reported a definition for PE-related death of which the most frequently used components were "autopsy-confirmed PE" (50%), "objectively confirmed PE before death" (55%), and "unexplained death" (58%). Median VTE case-fatality rate was 1.8% (interquartile range, 0.0-13).

CONCLUSIONS

Only half of the included studies reported definitions for PE-related death, which were very heterogeneous. Case-fatality rate of VTE events varied widely across studies. Standardization of the definition and guidance on adjudication and reporting of PE-related death is needed.

Comparison among different presentations of venous thromboembolism because of lung cancer

INTRODUCTION

Venous thromboembolism (VTE) because of lung cancer has been sufficiently studied, nevertheless, little is known regarding the discrepancy of clinical characteristics and predictive factors among different presentations of VTE because of lung cancer.

OBJECTIVES

This study was designed to investigate the distinction of clinical characteristics and predictive factors among different presentations of VTE because of lung cancer.

METHODS

All patients concomitant lung cancer and VTE were stratified into three groups: pulmonary embolism (PE) group in which patients had sole PE, deep vein thrombosis (DVT) group with sole DVT and concomitance group with both PE and DVT.

RESULTS

Concomitance of PE and DVT (28.2 days) mostly occurred at the early stage after the diagnosis of lung cancer, by contrast with DVT (63.6 days) which did at the latest stage, whereas PE (36.7 days) generally developed intermediately in between (P = .02). In a Kaplan-Meier analysis, the cumulative survival rate of DVT group was higher than that of concomitance group, whereas the rate of PE group lied in between. (P = .002) The strongest correlated factors with the development of DVT, PE and concomitance were adenocarcinoma (HR 3.27, P = .003), chemotherapy (HR 2.62, P = .005) and D-Dimer (HR 3.88, P < .001), respectively. The strongest correlated factors with the mortality of DVT, PE and concomitance were comorbidity (HR 2.32, P = .003), metastasis (HR 3.12, P < .001), and metastasis (HR 4.29, P < .001), respectively.

CONCLUSION

Concomitance of DVT and PE represents the severest state of lung cancer, the earliest occurrence of VTE, and the worst survival rate, whereas DVT stands for the mildest condition of lung cancer and stablest pattern of VTE.

Dimethylsphingosine and miltefosine induce apoptosis in lung adenocarcinoma A549 cells in a synergistic manner

Lung cancer is one of the most common and lethal types of oncological diseases. Despite the advanced therapeutic approaches, the prognosis for lung cancer still remains poor. Apparently, there is an imperative need for more efficient therapeutic strategies. In this work we report that concurrent treatment of human adenocarcinoma A549 cells with specific concentrations of two antitumor agents, the sphingosine kinase 1 inhibitor N, N dimethylsphingosine (DMS) and the alkylphosphocholine miltefosine, induced synergistic cytotoxic effect, which was confirmed by calculation of the combination index. The simultaneous action of these agents, induced significant decrease of A549 cell number, as well as pronounced morphological alterations. Combined drugs caused substantial apoptotic events, and significant reduction of the pro-survival marker sphingosine- 1-phosphate (S1P), when compared to the individual treatments with each of the anticancer drugs alone. Miltefosine is known to affect the synthesis of choline-containing phospholipids, including sphingomyelin, but we report for the first time that it also reduces S1P. Here we suggest a putative mechanism underlying the effect of miltefosine on sphingosine kinase 1, involving miltefosine-induced inhibition of protein kinase C. In conclusion, our findings provide a possibility for treatment of lung cancer cells with lower concentrations of the two antitumor drugs, DMS and miltefosine, which is favorable, regarding their potential cytotoxicity to normal cells.

Postoperative venous thromboembolism and mortality in patients with pancreatic surgery

BACKGROUND AND OBJECTIVES

Pancreatic cancer is strongly associated with thrombosis. We investigated early postoperative venous thromboembolism (PVTE) mortality among patients with pancreatic surgery and compared outcomes in adenocarcinoma pancreatic cancer (ACPC) to non-adenocarcinoma pancreatic neoplasm (NACPN).

METHODS

We analyzed a prospectively collected database of patients who underwent pancreatic cancer or neoplasm-related surgery. As NACPN is underrepresented in other studies, we selected NACPN patients and a random sample of ACPC patients. PVTE was defined as VTE occurring within 3 months of surgical intervention. Statistical analysis was performed using Cox proportional hazards regression.

RESULTS

A total of 441 pancreatic surgery patients were included, with 331 ACPC and 110 NACPN. Median follow-up was 449 days during which 90 (20.4%) patients developed VTE. PVTE occurred in 53 (12.0%) patients, including 41 (12.4%) ACPC patients and 12 (10.9%) NACPN patients. Those with PVTE had 60% higher mortality rate. A multivariable analysis found that PVTE is an independent predictor of increased mortality (HR Adj, 1.6; 95% CI, 1.1-2.2; P < .01). The mortality impact was not consistent between ACPC (HR, 3.2; 95% CI, 1.3-7.9) and NACPN groups (HR, 1.3; 95% CI, 0.9-1.8).

CONCLUSIONS

Postoperative venous thromboembolism is an independent predictor of increased mortality in pancreatic surgery, specifically in adenocarcinoma pancreatic cancer surgery.

A giant left atrial mass-Clinical treatment dilemma

A 74-year-old female current 75 pack-year smoker presented with shortness of breath and mild hemoptysis. Chest computed tomography showed a large right upper lobe mass compressing the superior vena cava, invading the right pulmonary veins, and occupying the majority of the left atrium. Brain magnetic resonance imaging revealed a 13 mm right parietal lesion with surrounding edema consistent with metastasis. A 3D TEE showed a large mobile mass in the left atrium. Bronchoscopy confirmed that the tumor mass was consistent with a moderately to poorly differentiated squamous cell carcinoma. She underwent chemotherapy, radiation, and immune therapy. She was also started on warfarin for anticoagulation after the initial chemotherapy with resolution of the left atrial mass. We feel that the patient most likely had carcinogenic thrombus in the pulmonary veins and left atrium.

Pancreatic cancer thromboembolic outcomes: rate of thrombosis after adenocarcinoma and non-adenocarcinoma pancreatic cancer surgery

BACKGROUND

The aim of this study was to define the association of non-adenocarcinoma pancreatic cancer (NACPC) as a risk factor for postoperative cancer-associated thrombosis (CAT).

METHODS

We conducted analysis of prospectively collected data of pancreatic cancer surgery. Randomly collected NACPC cases were matched 1:3 to adenocarcinoma cases (ACPC). Variables included comorbidities, demographics, cancer extension, and preoperative Khorana score (KRS). Primary outcome was CAT, which included deep vein thrombosis and pulmonary embolism confirmed by imaging. Categorical variables are presented as percentages, continuous variables as median and range. SPSS, χ2, Cochran-Armitage, and logistic regression were use for analysis.

RESULTS

The study included 441 patients. Age 65.9±11.5, male 57% (N.=252), 8% (N.=36) had metastasis. IPMN and neuroendocrine were the most common NACPC. Median follow-up was 449 days in which 90 (20%) patients developed CAT. The odds (Odds Ratio [OR] 1.1, 95% Confidence Interval [CI] 0.6- 1.9, P=0.7) and time to venous thromboembolism were not different between NACPC and ACPC. We analyzed for trends of prophylactic strategies by year of surgery; there was no trend for NACPC (P=0.4) or ACPC (P=0.06). KRS was not associated with CAT. In the multivariate analysis, peripheral artery disease (Adjusted Odds Ratio [ORadj] 5.4, 95% CI: 1.7-17.3), ASA class ≥4 (ORadj 3.6; 95% CI: 1.3-10.4), length of stay >9 days (ORadj: 1.9; 1.2-3.2), and cancer vascular invasion (ORadj: 2.9; 95% CI: 1.6-5.3) were associated with CAT.

CONCLUSIONS

The rate of VTE in NACPC after surgery was high and not different than ACPC. Histology type should not govern discrimination in thromboprophylaxis selection or extension.

Altered fibrin clot properties in advanced lung cancer: strong impact of cigarette smoking

BACKGROUND

Dense fibrin networks resistant to lysis have been reported in patients at high risk of thromboembolism. Little is known about fibrin clot properties in cancer. We investigated fibrin clot properties and their determinants in patients with inoperable lung cancer.

METHODS

We enrolled 150 patients with advanced lung cancer prior to therapy and 90 control subjects matched by age, sex, cardiovascular disease, and diabetes. Plasma clot permeability (K_s), turbidimetric analysis of clot formation, clot lysis time (CLT), microparticle-associated tissue factor (MP-TF) activity, thrombin generation, and serum cotinine levels were determined.

RESULTS

Lung cancer patients, compared with controls, formed at a faster rate (- 8.1% lag phase) denser plasma fibrin networks (- 27.2% K_s) that displayed impaired lysis (+ 26.5% CLT), along with 19.5% higher MP-TF activity and 100% higher peak thrombin generated, also after adjustment for potential confounders. Cotinine levels were associated with fibrin maximum absorbance (r = 0.20, p = 0.016) and K_s (r = - 0.50, p < 0.0001) in cancer patients. On multivariate regression analysis, an increase in cotinine levels was a predictor of low K_s (the lower quartile, < 5.8 × 10^-9 cm²; odds ratio = 1.21 per 10 ng/ml, 95% confidence interval 1.02-1.46), but not CLT.

CONCLUSION

Advanced lung cancer is associated with the prothrombotic plasma clot phenotype largely driven by smoking.

Altered fibrin clot properties in advanced lung cancer: impact of chemotherapy

Background

Faster formation of dense and poorly lyzable fibrin networks have been reported in patients at risk of thromboembolism, including cancer patients. We sought to investigate whether chemotherapy affects plasma fibrin clot properties and their determinants in lung cancer patients.

Methods

In this observational study we enrolled 83 consecutive patients with advanced inoperable lung cancer. Plasma fibrin clot permeability (K_s), turbidimetric analysis of clot formation, clot lysis time (CLT), microparticle-associated tissue factor (MP-TF) activity, and thrombin generation parameters were investigated at enrolment and 3-4 months after standard chemotherapy.

Results

Lung cancer patients after 4 (range, 4-5) cycles of chemotherapy had 35.6% higher D-dimer, 22.1% lower MP-TF activity, and unaltered fibrinogen compared with baseline. Chemotherapy resulted also in 7.5% increased K_s, 8.6% prolonged lag phase, and 5.4% shortened CLT, while thrombin generation was unchanged. Chemotherapy-related differences in clot structure were confirmed by scanning electron microscopy images. Fibrin clot properties after chemotherapy did not differ among histological types of lung cancer, cancer stages or chemotherapy regimens. Interestingly, never smoking (n=13, 16%) was associated with looser post-treatment fibrin structure as reflected by 12.3% higher K_s. Multiple linear regression showed that more advanced cancer stage, higher peak thrombin generation, and higher white blood cell count determined post-treatment change in K_s, while active smoking was associated with change in CLT.

Conclusions

Three-month chemotherapy in lung cancer patients improves clot properties despite unaffected thrombin generation, suggesting that anticancer treatment might quickly produce antithrombotic actions.

Characteristics and Impacts of Venous Thromboembolism in Patients with Hepatocellular Carcinoma

INTRODUCTION

Venous thromboembolism (VTE) is a common complication in cancer patients, and is associated with worse prognosis in such population. Hepatocellular carcinoma (HCC) poses high risk for VTE; however, data is scarce regarding the characteristics and consequences of VTE in HCC patients.

METHOD

We retrospectively reviewed the electronic medical records (EMR) of 270 patients diagnosed with HCC from 2000 to 2015 in Cook County Health and Hospitals System. We report the cumulative incidence of VTE in the present cohort, and identified through multivariate logistic regression the independent risk factors of the development of VTE. Overall prognosis of patients with and without VTE were presented and compared.

RESULTS

Sixteen cases (5.93%) of VTE were documented in the present study. In multivariate analysis, obesity, Child B cirrhosis, intra-hepatic lesions more than 3, and multi-organ extrahepatic metastasis were significantly associated with VTE development (p < 0.05). The presence of VTE was an independent risk factor for mortality in multivariate analysis (HR = 3.62, p = 0.021), together with male gender, Child C cirrhosis, and extrahepatic metastasis.

CONCLUSIONS

Obesity, Child B cirrhosis, more intra-hepatic lesions, and multi-organ extrahepatic metastasis are associated with cancer-associated VTE. VTE will adversely affect the prognosis of patients with HCC; therefore, primary thromboprophylaxis may be warranted in such population.

Coagulation biomarkers and prediction of venous thromboembolism and survival in small cell lung cancer: A sub-study of RASTEN - A randomized trial with low molecular weight heparin

Coagulation activation and venous thromboembolism (VTE) are hallmarks of cancer; however, there is an unmet need of improved biomarkers for individualized anticoagulant treatment. The present sub-study of the RASTEN trial was designed to explore the role of coagulation biomarkers in predicting VTE risk and outcome in a homogenous cancer patient population. RASTEN is a multicenter, randomized phase-3 trial investigating the survival effect of low molecular weight heparin enoxaparin when added to standard treatment in newly diagnosed small cell lung cancer (SCLC) patients. Plasma collected at baseline, during treatment, and at follow-up was used in this ad hoc sub-study (N = 242). Systemic coagulation was assessed using four assays reflecting various facets of the coagulation system: Total tissue factor (TF); extracellular vesicle associated TF (EV-TF); procoagulant phospholipids (PPL); and thrombin generation (TG). We found small variations of biomarker levels between baseline, during treatment and at follow-up, and appeared independent on low molecular weight heparin treatment. Overall, none of the measured biomarkers at any time-point did significantly associate with VTE incidence, although increased total TF at baseline showed significant association in control patients not receiving low molecular weight heparin (P = 0.03). Increased TG-Peak was significantly associated with decreased overall survival (OS; P = 0.03), especially in patients with extensive disease. Low baseline EV-TF predicted a worse survival in the low molecular weight heparin as compared with the control group (HR 1.42; 95% CI 1.04–1.95; P = 0.03; P for interaction = 0.12). We conclude that the value of the analyzed coagulation biomarkers for the prediction of VTE risk was very limited in SCLC patients. The associations between TG-Peak and EV-TF with patient survival and response to low molecular weight heparin therapy, respectively, warrant further studies on the role of coagulation activation in SCLC aggressiveness.

[Risk Factors Associated with Venous Thromboembolism after Lung Cancer Surgery: A Single-center Study]

BACKGROUND

The Previous study has indicated that the incidence of venous thromboembolism (VTE) after lung cancer surgery is not uncommon. The aim of this study is to analyze the risk factors of postoperative VTE in lung cancer patients and provide a clinical basis for further prevention and treatment of VTE.

METHODS

This study was a single-center study. From July 2016 to December 2017, all patients with lung cancer who underwent surgery in our department were enrolled into this study. Except routine preoperative examinations, lower extremity Doppler ultrasound was performed in all patients before and after surgery to determine whether there was any newly developed deep venous thrombosis (DVT). Patients did not receive any prophylactic anticoagulant therapy before and after surgery. Patients were then divided into VTE group and control group according to whether VTE occurred after operation. Baseline data, surgical related data (surgery type, surgical procedure, etc.) and tumor pathological data (pathological type, vascular infiltration, pathological staging, etc.) were compared between the two groups.

RESULTS

According to the inclusion criteria, a total of 339 patients undergoing lung cancer surgery were analyzed. There were 166 males and 173 females with an age range of 23-86 years. A total of 39 patients developed VTE after surgery, the incidence rate of postoperative VTE was 11.5%. Comparing the age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA), smoking status, underlying diseases, etc, there were no significant differences in other indicators except for significant differences in age; comparison between preoperative blood routine, blood biochemistry, coagulation, tumor markers, lung function, lower extremity venous ultrasound, preoperative carcinoembryonic antigen (CEA) levels, preoperative D-dimer levels, there were significant differences in lung function and lower extremity intermuscular vein expansion ratio. There were no significant differences in other indexes between the two groups. The duration of surgery, surgical procedure, bleeding volume, pathological type, pathological stage, vascular invasion, were compared between the two groups. There were statistical differences in surgical methods (thoracic vs thoracoscopic) and bleeding volume. There were no significant differences in other indicators. Univariate analysis showed that age, preoperative CEA level, preoperative D-dimer level, poor pulmonary function, lower extremity intermuscular vein dilation ratio, thoracotomy rate, length of surgery, and amount of bleeding were significantly risk factors (P<0.05). There were no significant correlations between pathological stage and pathological type and VTE. Multivariate logistic regression analysis showed that forced expiratory volume in one second (FEV1), surgical approach, and lower extremity intermuscular vein dilatation were independent risk factors for postoperative VTE in patients with lung cancer (P<0.05).

CONCLUSIONS

The results of this study suggest that FEV1, surgical procedures, and lower extremity intermuscular vein dilation are independent risk factors for postoperative VTE in patients with lung cancer.

Khorana Score: Νew Predictor of Early Mortality in Patients With Lung Adenocarcinoma

Venous thromboembolism (VTE) is a typical complication in patients with lung cancer. Khorana score is an established tool for thromboembolic risk stratification of ambulatory patients with cancer undergoing outpatient chemotherapy. The aim of this study was to evaluate the predictive value of the Khorana score for VTE and death in patients with lung adenocarcinoma during first-line or adjuvant chemotherapy. Medical records of 130 patients with lung adenocarcinoma receiving first-line or adjuvant chemotherapy were retrospectively studied during the time period June 2013 to May 2015. Venous thromboembolism occurred in 13 (10.0%) patients. Thromboembolic events were significantly correlated with reduced survival during treatment period (hazard ratio [HR]: 3.24; 95% confidence interval [CI]: 1.11-9.49; P = .032). The VTE rates did not present statistically significant difference between different Khorana score groups ( P = .96). In univariate analysis, the risk of death during treatment period (median: 16 weeks) was 3.75 times higher in high-risk versus intermediate-risk patients (HR: 3.75, 95% CI: 1.36-10.36; P = .001) and had 2.25 times higher per point increase in the Khorana score (HR: 2.25, 95% CI: 1.36-3.73; P = .002); the above results were also reproduced in multivariate analysis. Khorana score represents a valuable tool for identifying patients with cancer in low thromboembolic risk but does not preserve its predictive value for higher risk individuals. Khorana score is an independent risk factor for death in patients with lung adenocarcinoma receiving first-line or adjuvant chemotherapy.

Association between oncogenic status and risk of venous thromboembolism in patients with non-small cell lung cancer

Background

Preclinical data suggest that oncogene (EGFR and KRAS) events regulate tumor procoagulant activity. However, few studies have prospectively investigated the clinical relevance between the presence of EGFR or KRAS mutations and occurrence of venous thromboembolism(VTE) in patients with non-small cell lung cancer (NSCLC).

Methods

A total of 605 Chinese patients with newly diagnosed NSCLC were included and were followed for a maximum period of 4.5 years. EGFR and KRAS mutations were determined by amplification refractory mutation system polymerase chain reaction method at inclusion. The main outcome was objectively confirmed VTE.

Results

Of the 605 patients, 40.3% (244) had EGFR mutations and 10.2% (62) of patients had KRAS mutations. In multivariable analysis including age, sex, tumor histology, tumor stage, performance status, EGFR and KRAS status, EGFR wild-type (sub-distribution hazard ratio 1.81, 95% confidence interval 1.07–3.07) were associated with the increased risk of VTE. In competing risk analysis, the probability of developing VTE was 8.3% in those with and 13.2% in those without EGFR mutations after 1 year; after 2 years, the corresponding risks were 9.7 and 15.5% (Gray test P = 0.047).

Conclusions

EGFR mutations have a negative association with the risk of VTE in Chinese patients with NSCLC.