Epidemiology and risk factors for venous thromboembolism in lung cancer

Activated factor XI-antithrombin and thrombin-antithrombin complexes in the prediction of venous thromboembolism and mortality in patients with non-small-cell lung cancer

BACKGROUND

Patients with non-small cell lung cancer (NSCLC) are at high risk of venous thromboembolism (VTE), especially during chemotherapy. Even though the contact system is implicated in the pathogenesis of thrombosis, limited data are available on the role of contact system activation in NSCLC-associated VTE.

OBJECTIVES

In a prospective cohort of patients with NSCLC starting chemotherapy, contact system activation and thrombin generation biomarkers were assessed in relation to 6-month VTE occurrence and mortality.

METHODS

Prechemotherapy plasma samples of 719 newly diagnosed patients with NSCLC were tested for in vivo biomarkers of contact system activation (ie, kallikrein [pKa]:antithrombin [AT; PKa:AT], activated factor [F]XI:AT [FXIa:AT], FXIa:C1-esterase inhibitor C1Inh [FXIa:C1Inh], activated FIX:AT [FIXa:AT]), and thrombin generation (ie, prothrombin fragment 1+2 [F1+2] and thrombin-antithrombin complex [TAT]). Clinical data, VTE, and mortality were recorded prospectively.

RESULTS

The 6-month VTE and mortality cumulative incidences were 11% and 27%, respectively. Basal levels of FXIa:AT complexes, F1+2, and TAT were higher in patients who developed VTE than those in VTE-free patients. Differently, PKa:AT, FIXa:AT, and TAT were lower in survivors than those in nonsurvivors. The multivariable analysis identified FXIa:AT (subdistribution hazard ratio, 1.17; 95% CI, 1.00-1.37) and TAT (subdistribution hazard ratio, 1.28; 95% CI, 1.10-1.50) as VTE-independent risk factors during chemotherapy. A score based on these biomarkers was generated, which was able to discriminate patients at significantly higher rates of VTE and mortality.

CONCLUSION

Elevated in vivo contact pathway activation and thrombin generation were observed in patients with NSCLC who developed VTE. Furthermore, a score based on both FXIa:AT and TAT levels was developed to identify those patients at higher risk of VTE and mortality.

Cancer genetic profile and risk of thrombosis

Cancer-associated thrombosis (CAT) remains a leading cause of morbidity and mortality among oncology patients, with an incidence influenced by tumor type, stage, treatment, and molecular characteristics. This review explores the molecular determinants of venous thromboembolism (VTE) in cancer, emphasizing its pathophysiology and association with specific oncogenic alterations. Certain molecular profiles exhibit heightened VTE risk. In lung cancer, due to hypercoagulability mechanisms linked to tissue factor overexpression, an increased incidence of VTE has been reported in populations with ALK (30-40 %) and ROS1 rearrangements (34.7-46.6 %). In gastrointestinal cancers, while pancreatic adenocarcinoma has the highest VTE rates (up to 22 %), KRAS mutations seem to be implicated but not conclusively validated. Similarly, colorectal cancer mutations (KRAS/BRAFV600E) and antiangiogenic therapies may elevate thrombotic risk, warranting further study. High-grade gliomas, particularly glioblastomas, present VTE rates up to 30 %, driven by podoplanin-induced platelet aggregation. IDH1 mutations inversely correlate with thrombosis, highlighting its protective role. Emerging evidence suggests that agnostic biomarkers such as STK11 mutations influence VTE risk across tumor types, while others like KRAS, MET and BRCA mutations show inconclusive results. Large-scale validation studies are imperative to integrate molecular profiles into clinical practice. Until then, management decisions should be individualized, balancing the thrombotic risks with oncologic considerations.

Development and Validation of a Modified Khorana Score for Predicting Venous Thromboembolism in Newly Diagnosed Stage IV Lung Cancer

We aimed to establish an effective model to identify metastatic lung cancer patients at high risk of venous thromboembolism (VTE). Patients diagnosed with stage IV lung cancer from January 2011 to June 2019 were included in the development cohort; those recruited from July 2019 to June 2021 were included in the validation cohort. Univariable and multivariable analyses determined the risk factors for VTE. Then we assessed the value for predicting VTE of the Khorana score and modified Khorana score in these two cohorts; 575 patients were included in the development cohort, and 202 patients in the validation cohort. Adenocarcinoma, D-dimer, and the Khorana score were independent risk factors for VTE. In the development cohort, the area under the receiver operating characteristic curve (AUC) of the Khorana score in patients with newly diagnosed stage IV lung cancer was 0.598 (95% CI, 0.512-0.684). The AUC of the modified Khorana score was 0.747 (95% CI, 0.689-0.805). The difference was statistically significant (P <.001). The AUC of the modified Khorana score in the validation cohort was 0.763 (95% CI, 0.661-0.865). The modified Khorana score is more able to accurately predict VTE in patients with newly diagnosed stage IV lung cancer than the Khorana score.

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).

Early identification of lung cancer patients with venous thromboembolism: development and validation of a risk prediction model

INTRODUCTION

Venous thromboembolism(VTE) is a leading cause of death in patients with lung cancer. Furthermore, hospitalization of patients with advanced lung cancer for VTE treatment represents a major economic burden on the national public health resources. Therefore, we performed this prospective study to identify clinical biomarkers for the early identification of VTE in lung cancer patients.

METHODS

This prospective study enrolled 158 patients with confirmed lung cancer, including 27 who were diagnosed with VTE within six months of the follow-up after lung cancer diagnosis. Multivariate logistic regression analysis was used to evaluate the diagnostic performancese of all the relevant clinical features and laboratory indicators in identifying lung cancer patients with a higher risk of VTE. A novel risk prediction model was constructed consisting of five clinical variables with the best diagnostic performances and was validated using the receiver operation characteristic(ROC) curves. The diagnostic performances of the new risk prediction model was also compared with the Khorana risk score (KRS) and the Padua risk score (PRS).

RESULTS

The VTE group of lung cancer patients (n = 27) showed significantly higher serum levels of fibrin degradation products (FDP), D-dimer, thrombomodulin (TM), thrombin-antithrombin-complex (TAT), α2-plasmin inhibitor-plasmin Complex (PIC), and tissue plasminogen activator-plasminogen activator inhibitor complex (t-PAIC) compared to those in the non-VTE group (n = 131). ROC curve analyses showed that the diagnostic efficacy of the new VTE risk prediction model with TM ≥ 9.75 TU/ml, TAT ≥ 2.25ng/ml, t-PAIC ≥ 7.35ng/ml, history of VTE, and ECOG PS score ≥ 2 was superior than the KRS and the PRS in the early identification of lung cancer patients with a higher risk of VTE.

CONCLUSIONS

The new risk prediction model showed significantly high diagnostic efficacy in the early identification of lung cancer patients with a high risk of VTE. The diagnostic efficacy of the new risk prediction model was higher than the KRS and the PRS in this cohort of lung cancer patients.

Could PD-L1 positivity be associated with venous thrombosis in patients with non-small cell lung cancer?

The risk of venous thromboembolism (VTE) is increased in non-small cell lung cancer (NSCLC), and defining at-risk patients is important. Thus, we aimed to assess the association between programmed cell death ligand 1 (PD-L1) expression and VTE [pulmonary embolism (PE), deep venous thrombosis (DVT)] in NSCLC. In this retrospective, observational multicentre study, 369 patients with NSCLC who had PD-L1 immunohistochemistry based on biopsies taken between January 2017 and December 2019, were divided as PD-L1-positive (n = 181) and -negative (n = 188) groups, and low-positive (n = 99) and high-positive (n = 82) PD-L1 groups. Among all population, 12.5% of them developed a VTE during a median follow-up of 474 days. The rates of DVT, PE, and PE + DVT were 5.7%, 6% and 0.8%, respectively. VTE (15.5% vs. 9.5%) and DVT (3.8% vs. 7.4%) were similar between two groups, while PE was significantly higher in PD‑L1-positive group than those in PD-L1-negative group (11.1% vs 1%, p < 0.001). There were no significant differences between low- and high-positive groups in terms of VTE (14.1% vs. 17%), PE (12.1% vs. 9.8%), and DVT (2% vs. 6.1%). In the multivariate analysis, multiple metastases (Hazard ratio [HR] 4.02; 95% confidence interval [Cl] 1.18-13.63; p = 0.07) and PD-L1 positivity was associated with an increased PE risk (HR 8.39; 95% Cl 2.07-34.07; p = 0.003). In conclusion, PD-L1 positivity may be of important role in predicting the increased risk of PE in patients with NSCLC and thereby may be used to define patients likely to benefit from thromboprophylaxis.

Circulating D-Dimers Increase the Risk of Mortality and Venous Thromboembolism in Patients With Lung Cancer: A Systematic Analysis Combined With External Validation

Background

D-dimer is a fibrin-degrading substance that is soluble and whose degradation is produced by plasma protein-mediated degradation of cross-linked fibrin. Previous investigations have shown a link between D-dimer and the mortality in lung cancer patients. However, different investigations varied whether D-dimer could predict prognosis in these patients.

Methods

A meta-analysis and systematic review of all available cohort studies were performed on the link between circulating D-dimer levels and survival of lung cancer patients. Relevant studies were searched in Embase, Cochrane Library, and PubMed databases. Data from 540 lung cancer patients from the First Hospital of Soochow University and Sichuan Cancer Hospital were used for external validation.

Results

We finally obtained 19 eligible cohort studies with pooled HR showing that high D-dimer levels contribute to death in tumor group (HR 1.62, 95% CI: 1.39-1.88, I² = 75.0%). Further stratified analysis showed that higher circulating D-dimer in the advanced lung cancer group was linked to a 1.91-fold risk (HR = 2.91, 95% CI: 2.24-3.78, I² = 6.0%). Incorporation of other variables, including days of follow-up, country, design, public year, population, disease status, and quality score, into the meta-regression model, indicated that disease status was an additional source of heterogeneity (p < 0.001). External validation of 540 patients also showed that high levels of D-dimer showed a higher risk of overall mortality (HR 1.39, 95% CI: 1.13-1.72, p = 0.002) and VTE events (HR 3.98, 95% CI: 1.99-8.70, p = 0.002) in lung cancer patients.

Conclusions

High circulating plasma D-dimer levels independently predict long-term prognosis and the risk of venous thromboembolism in lung cancer.

Optimal authoritative risk assessment score of Cancer-associated venous thromboembolism for hospitalized medical patients with lung Cancer

Background

Cancer-associated venous thromboembolism (VTE) is common in patients with primary lung cancer. It has been understudied which authoritative risk assessment score of cancer-associated VTE is optimal for the assessment of VTE development in hospitalized medical patients with lung cancer.

Methods

Patients with lung cancer who had undergone computed tomography pulmonary angiography (CTPA), compression ultrasonography (CUS) of lower and upper extremities, and/or planar ventilation/perfusion (V/Q) scan to confirm the presence or absence of VTE during a medical hospitalization were retrospectively reviewed. Based on the actual prevalence of VTE among all patients, the possibility of VTE were reassessed with the Khorana score, the PROTECHT score, the CONKO score, the ONKOTEV score, the COMPASS-CAT score, and the CATS/MICA score, to compare their assessment accuracy for VTE development.

Results

A total of 1263 patients with lung cancer were incorporated into the final analysis. With respect to assessment efficiency for VTE occurrence, the scores with adjusted agreement from highest to lowest were the ONKOTEV score (78.6%), the PROTECHT score (73.4%), the CONKO score (72.1%), the COMPASS-CAT score (71.7%), the Khorana score (70.9%), and the CATS/MICA score (60.3%). The ONKOTEV score had the highest Youden index which was 0.68, followed by the PROTECHT score (0.58), the COMPASS-CAT score (0.56), the CONKO score (0.55), the Khorana score (0.53), and the CATS/MICA score (0.23).

Conclusions

Among the Khorana score, the PROTECHT score, the CONKO score, the ONKOTEV score, the COMPASS-CAT score, and the CATS/MICA score which are approved by authoritative guidelines, the ONKOTEV score is optimal for the assessment of VTE development in hospitalized medical patients with lung cancer.

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.

Safety profile of preoperative administration of low-molecular-weight heparin on minimally invasive lung cancer surgery: a randomized controlled trial

Background

Venous thromboembolism remains a common but preventable complication for cancerous lung surgical patients. Current guidelines recommend thromboprophylaxis for lung patients at high risk of thrombosis, while a consensus about specific administration time is not reached. This study was designed to investigate the safety profile of preoperative administration of low-molecular-weight-heparin (LMWH) for lung cancer patients.

Methods

From July 2017 to June 2018, patients prepared to undergo lung cancer surgery were randomly divided into the preoperative LMWH-administration group (PRL) for 4000 IU per day and the postoperative LMWH-administration group (POL) with same dosage, all the patients received thromboprophylaxis until discharge. Baseline characteristics including demographics and preoperative coagulation parameters were analyzed, while the endpoints included postoperative coagulation parameters, postoperative drainage data, hematologic data, intraoperative bleeding volume and reoperation rate.

Results

A total of 246 patients were collected in this RCT, 34 patients were excluded according to exclusion criterion, 101 patients were assigned to PRL group and 111 patients belonged to POL group for analysis finally. The baseline characteristic and preoperative coagulation parameters were all comparable except the PRL group cost more operation time (p = 0.008) and preoperative administration duration was significantly longer (p < 0.001). The endpoints including postoperative day 1 coagulation parameters, mean and total drainage volume, drainage duration, intraoperative bleeding volume and reoperation rate were all similar between the two groups. Moreover, coagulation parameters for postoperative day 3 between the two groups demonstrated no difference.

Conclusion

Preoperative administration of low-molecular-weight-heparin demonstrated safety and feasibility for lung cancer patients intended to receive minimally invasive surgery.

Trial registration: ChiCTR2000040547 (www.chictr.org.cn), 2020/12/1, retrospectively registered.

Driver Genes Associated With the Incidence of Venous Thromboembolism in Patients With Non-Small-Cell Lung Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

The association between driver genes and the incidence of thromboembolic events (TEs) in patients diagnosed with non-small-cell lung cancer (NSCLC) needs to be quantified to guide clinical management.

METHODS

We interrogated PubMed, Embase, Web of Science and Cochrane library databases for terms related to venous thromboembolism (VTE) and arterial thromboembolism (ATE) in patients diagnosed with non-small-cell lung cancer harboring driver genes. This search was conducted for studies published between 1 January, 2000 and 31 December, 2020. A random-effects meta-analysis was performed to analyze the pooled incidence and odds ratios of VTE in patients with different driver genes.

RESULTS

Of the 2,742 citations identified, a total of 25 studies that included 21,156 patients met eligibility criteria. The overall pooled incidence of VTE in patients with driver genes was 23% (95% CI 18-29). Patients with ROS1 rearrangements had the highest incidence of VTE (37%, 95%CI 23-52). ALK rearrangements were associated with increased VTE risks (OR=2.08,95% CI 1.69-2.55), with the second highest incidence of VTE (27%, 95%CI 20-35). Both groups of patients with EGFR and KRAS mutations did not show a significantly increased risk for VTE (OR=1.33, 95% CI 0.75-2.34; OR=1.31, 95% CI 0.40-4.28).

CONCLUSIONS

ALK rearrangements were shown to be associated with increased VTE risks in patients diagnosed with non-small lung cancer, while there was no significant relation observed between VTE risks and EGFR or KRAS mutations in lung cancer patients.

A modified Khorana score as a risk assessment tool for predicting venous thromboembolism in newly diagnosed advanced lung cancer

The aim of this study was to evaluate the Khorana score and modified Khorana score as risk assessment tools for predicting the development of VTE in newly diagnosed advanced lung cancer. Information on the clinical data and laboratory indicators of the study group between 2014 and 2018 and the validation group between January 2019 to June 2020 of newly diagnosed advanced lung cancer patients at The First Affiliated Hospital of Henan University of Science and Technology was collected. We conducted an analysis of the risk factors affecting VTE development and the predictive risk value of the Khorana score and the modified Khorana score for VTE in newly diagnosed advanced lung cancer patients. A total of 124 patients were included in the study group. D-dimer is an independent risk factor for VTE in newly diagnosed advanced lung cancer patients (OR 1.620, 95% CI 1.220, 2.152, p = 0.001). The best cutoff value of D -dimer for the prediction of VTE development risk was 1.14 mg/L. The AUC of the Khorana score to predict the occurrence risk of VTE in newly diagnosed advanced lung cancer patients was 0.706; when the best cutoff value was 2, the sensitivity was 70.83%, and the specificity was 65%. The AUC of the modified Khorana score was 0.870; when the cutoff value was 2, the sensitivity was 100%, and the specificity was 50%. A total of 237 patients were included in the validation group, the AUC of the modified Khorana score for predicting the occurrence risk of VTE was 0.875; when the cutoff value was 2, the sensitivity was 100%, and the specificity was 52.1%. The modified Khorana score after incorporating D-dimer has a higher predictive value for the occurrence risk of VTE in newly diagnosed lung cancer patients; when the score ≥ 2, its sensitivity is higher, and it can more fully identify high-risk groups of VTE.

Development and Validation of a Risk Score for Prediction of Venous Thromboembolism in Patients With Lung Cancer

This study aimed to develop and validate a risk score for early prediction of venous thromboembolism (VTE) in patients with lung cancer. A total of 827 patients with lung cancer from February 2013 to February 2018 in our hospital were retrospectively analyzed. Demographic and clinicopathological variables independently correlated to VTE were applied to develop the risk score in the development group while examined in the validation group. The regression coefficients of multivariable logistic regression test were applied to assign a risk score system. The incidence of VTE was 12.3%, 12.7%, and 11.8% in all patients, in the development and validation groups, respectively. The 496 patients in the development group were classified into 3 groups: low risk (scores ≤3), moderate risk (scores 4-5), and high risk (scores ≥6). The risk of VTE was significantly and positively related to the risk scores in both development and validation groups. The risk score system aided proper stratification of patients with either high or low risk of VTE in the development and validation groups (c statistic = 0.819 and 0.827, respectively). This risk score system based on the factors with most significant correlation showed good predictive ability and is potentially useful for predicting VTE in patients with lung cancer. However, it was developed and validated by a retrospective analysis and has significant limitations, and a prospective validation with all the classic variables assessing the thrombotic risk is needed for a solid conclusion.

Application of Thromboelastography to Predict Lung Cancer Stage

Objective:

Lung cancer is often associated with hypercoagulability. Thromboelastography provides integrated information on clot formation in whole blood. This study explored the possible relationship between thromboelastography and lung cancer.

Methods:

Lung cancer was staged according to the Tumor, Node, and Metastasis (TNM) classification system. Thromboelastography parameters in different stages of disease were compared. The value of thromboelastography for stage prediction was determined by area under the receiver operating characteristic curve analysis.

Results:

A total of 182 patients diagnosed with lung cancer were included. Thromboelastography parameters, including kinetics time, α-angle, and maximum amplitude, differed significantly between patients with metastatic and limited lung cancers (P < 0.05). Kinetics time was significantly reduced and maximum amplitude was significantly increased in patients with stage I and II compared with stage III and IV tumors (P < 0.05). TNM stage was significantly negatively correlated with kinetics time (r = −0.186), and significantly positively correlated with α-angle (r = 0.151) and maximum amplitude (r = 0.251) (both P < 0.05). The area under the curve for kinetics time in patients with stage I cancer was 0.637 (P < 0.05) and that for α-angle in stage ≥ II was 0.623 (P < 0.05). The areas under the curves for maximum amplitude in stage ≥ III and stage IV cancer were 0.650 and 0.605, respectively (both P < 0.05). Thromboelastography parameters were more closely associated with TNM stage in patients with lung adenocarcinoma than in the whole lung cancer population.

Conclusion:

This study identified the diagnostic value of thromboelastography parameters for determining tumor stage in patients with lung cancer. Thromboelastography can be used as an independent predictive parameter for lung cancer severity.

Impact of Tumor Genomic Mutations on Thrombotic Risk in Cancer Patients

Venous thromboembolism (VTE) is common in patients with cancer and is an important contributor to morbidity and mortality in these patients. Early thromboprophylaxis initiated only in those cancer patients at highest risk for VTE would be optimal. Risk stratification scores incorporating tumor location, laboratory values and patient characteristics have attempted to identify those patients most likely to benefit from thromboprophylaxis but even well-validated scores are not able to reliably distinguish the highest-risk patients. Recognizing that tumor genetics affect the biology and behavior of malignancies, recent studies have explored the impact of specific molecular aberrations on the rate of VTE in cancer patients. The presence of certain molecular aberrations in a variety of different cancers, including lung, colon, brain and hematologic tumors, have been associated with an increased risk of VTE and arterial thrombotic events. This review examines the findings of these studies and discusses the implications of these findings on decisions relating to thromboprophylaxis use in the clinical setting. Ultimately, the integration of tumor molecular genomic information into clinical VTE risk stratification scores in cancer patients may prove to be a major advancement in the prevention of cancer-associated thrombosis.

Risk Factors and Clinical Significance of D-Dimer in the Development of Postoperative Venous Thrombosis in Patients with Lung Tumor

BACKGROUND

The incidence of venous thromboembolism (VTE) is higher in patients with lung cancer. The aim of this study was to investigate the risk factors associated with postoperative VTE and explore the VTE predication capacity of D-dimer kinetics.

PATIENTS AND METHODS

Six hundred patients who had lung tumor surgery were analyzed retrospectively between January 2018 and August 2019, and venous ultrasound imaging and D-dimer examination before and after surgery were recommended to all operative patients. Of these 600 patients, 523 patients had venous thromboembolism after surgery, and 77 patients had not found. The general clinical data, postoperative prophylactic anticoagulant therapy, early systemic thromboprophylaxis, 50% increment of D-dimer, 100% increment of D-dimer, and perioperative (preoperative and days 1, 3, and 5 after surgery) D-dimer levels were collected. Logistic regression analysis was used to analyze the independent risk factors of postoperative VTE.

RESULTS

VTE developed in 77 (12.8%) patients. In a univariate analysis, age, surgical approach, tumor size, histology, postoperative preventive anticoagulation, postoperative limb compression therapy, postoperative hemostasis, duration of operation, early systemic thromboprophylaxis, 100% increment of D-dimer, preoperative and postoperative D-dimer level, intraoperative blood loss, and time spent in the hospital were significantly different between the thrombus group and nonthrombus group (P < 0.05). Multivariate analysis showed that age >60 years (P = 0.006) and D-dimer level on 5 days after surgery (P = 0.000) were significant independent risk factors for VTE. Postoperative D-dimer was significantly higher than the preoperative level (P < 0.001). Postoperative D-dimer level was significantly different between benign and malignant tumor groups (P < 0.05) and between the thrombus group and nonthrombus group (P < 0.001). Preventive anticoagulation and limb compression therapy starting from the first day after surgery was statistically significant between the thrombus group and the nonthrombus group (P < 0.05).

CONCLUSION

Continuous detection of D-dimer level after pulmonary tumor surgery combined with thrombotic-related risk factors can better evaluate the occurrence of VTE. Preventive anticoagulant therapy and limb compression therapy starting from the first day after surgery can effectively reduce the incidence of VTE.

Association between microRNA 25 expression in serum and lung cancer: A protocol for systematic review and meta-analysis

BACKGROUND

This study aims to identify the association between microRNA 25 (mRNA 25) expression in serum and lung cancer (LC).

METHODS

This planned study will cover all eligible case-controlled studies that report association between mRNA 25 expression in serum and LC. It will include published studies from inception to the present in Cochrane Library, PUBMED, EMBASE, Web of Science, Allied and Complementary Medicine Database, VIP database, and China National Knowledge Infrastructure regardless language and geographical location. We will also search other sources, such as conference abstracts and reference lists of related known studies and experts in the domain consulted to avoid missing potential studies. Two contributors will independently examine and select studies, collect all necessary data, and judge study quality for all included studies. We will perform statistical analysis using RevMan V.5.3 software and Stata V.12.0 software.

RESULTS

This study will summarize current evidence to present first systematic review of research on the association between mRNA 25 expression in serum and LC.

CONCLUSION

This study will present comprehensive evidence to determine whether mRNA 25 expression in serum is associated with LC, and will provide helpful evidence for the future studies.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202040056.

Clinical features of pulmonary embolism in patients with lung cancer: A meta-analysis

Background

Pulmonary embolism (PE) is correlated with increased mortality among patients with lung cancer (LC). The characteristics of patients with LC presenting with PE have not been fully established, and our meta-analysis aims to comprehensively investigate the clinical characteristics associated with PE in patients with LC to help physicians identify PE earlier in these patients.

Methods

Multiple databases were searched, including PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure and Wanfang. Odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (95% CIs) were used as effect measures for dichotomous and continuous variables, respectively. Moreover, Egger’s test, Begg’s test and a sensitivity analysis were performed to assess the publication bias and reliability of the articles.

Results

In total, 16 studies were included in our meta-analysis. The results indicated that history of chronic obstructive pulmonary disease (OR = 2.59, 95% CI: 1.09, 6.15; P = 0.03), adenocarcinoma (OR = 2.28, 95% CI: 1.88, 2.77; P < 0.01), advanced tumour stage (TNM III-IV vs. I-II, OR = 2.38, 95% CI: 1.99, 2.86; P < 0.01), history of central venous catheter (OR = 1.95, 95% CI: 1.36, 2.78; P < 0.01), history of chemotherapy (OR = 2.32, 95% CI: 1.80, 2.99, P < 0.01), high levels of D-dimer (WMD = 4.31, 95% CI: 2.53, 6.10; P < 0.01) and carcinoembryonic antigen (WMD = 10.30, 95% CI: 9.95, 10.64; P < 0.01) and a low level of partial pressure of oxygen (WMD = -25.97, 95% CI: -31.31, -20.62; P < 0.01) were clinical features of LC patients with PE compared to those without PE.

Conclusions

These results reveal that LC patients with PE have specific clinical features, including but not limited to several cancer- and treatment-related factors, that may help their early identification.

Association of Preoperative Plasma D-dimmer and Fibrinogen and Renal Cell Carcinoma Outcome

Background: the plasma D-dimer and fibrinogen which are indicators of coagulation-fibrinolysis system has been reported to be associated with survival in several types of cancers, including RCC. The aim of our study was to assess the prognostic significance of preoperative plasma D-dimer and fibrinogen levels in RCC patients. Methods: Data from 449 patients with RCC were assessed retrospectively. Cutoff value for plasma D-dimer and fibrinogen were tested by the standardized cutoff-finder algorithm. Overall survival (OS) and disease-free survival (DFS) were evaluated using the Kaplan-Meier method. Univariate and Multivariate Cox regression models were further applied for two end points. Results: Multivariate analysis identified increased plasma D-dimer and fibrinogen as independent prognostic factors for OS (D-dimer, P=0.017; Fibrinogen, P=0.049) and DFS (D-dimer, P=0.038; Fibrinogen, P<0.001). Moreover, all the patients were stratified using these two factors in the following ways: (1) Low risk: both level of plasma D-dimer and fibrinogen were no more than cutoff value. (2) Intermediate risk: neither low risk nor high risk, (3) high risk: both level of plasma D-dimer and fibrinogen were higher than cutoff value. This model showed significant predictive power for OS and DFS. Conclusion: preoperatively elevated D-dimer and fibrinogen can be regard as independent predictors for patients' prognosis in RCC. Combining both plasma D-dimer and fibrinogen can improve the prognostic accuracy and easy accessibility in clinical practice.

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.

Prospective Assessment of Clinical Risk Factors and Biomarkers of Hypercoagulability for the Identification of Patients with Lung Adenocarcinoma at Risk for Cancer-Associated Thrombosis: The Observational ROADMAP-CAT Study

BACKGROUND

The aim of this prospective study was to identify the most clinically relevant hypercoagulability biomarkers in lung adenocarcinoma patients for elaboration of an improved risk assessment model (RAM) for venous thromboembolism (VTE).

SUBJECTS, MATERIALS, AND METHODS

One hundred fifty ambulatory patients with lung adenocarcinoma were prospectively enrolled. Thrombin generation, procoagulant phospholipid-dependent clotting time (Procoag-PPL), tissue factor activity (TFa), factor VIIa (FVIIa), factor V (FV), antithrombin, D-Dimers, P-selectin, and heparanase levels were assessed in platelet-poor plasma at inclusion (baseline) and at the end of the third chemotherapy cycle (third chemotherapy). Cox regression analysis was used to identify independent VTE predictors.

RESULTS

At baseline, patients had significantly attenuated thrombin generation, shorter Procoag-PPL, higher levels of TFa, D-Dimers, and heparanase, and lower levels of FVIIa and P-selectin, compared with controls. A significant increase in Procoag-PPL, FV, and FVIIa and a decrease of P-selectin levels were observed between baseline and third chemotherapy. Hospitalization within the last 3 months prior to assessment, time since cancer diagnosis less than 6 months, mean rate index (MRI) of thrombin generation, and Procoag-PPL were independently associated with symptomatic VTE. Accordingly, a prediction model including Procoag-PPL and MRI showed significant discriminating capacity (area under the curve: 0.84).

CONCLUSION

Ambulatory patients with lung adenocarcinoma may display pronounced blood hypercoagulability due to decreased Procoag-PPL, increased endothelial cell activation, and increased degradation of fibrin. Incorporation of Procoag-PPL and MRI of thrombin generation may improve the accuracy of a VTE-RAM in the above setting.

IMPLICATIONS FOR PRACTICE

The prospective ROADMAP-CAT study identified two biomarkers of hypercoagulability, the procoagulant phospholipid-dependent clotting time (Procoag-PPL) and the mean rate index (MRI) of the propagation phase of thrombin generation assessed with the Calibrated Automated Thrombinoscope, as being clinically relevant for the classification of ambulatory patients with lung adenocarcinoma receiving a maximum of one cycle of chemotherapy into high and intermediate/low risk for venous thromboembolism. Measurement of Procoag-PPL and MRI within 1 month after the administration of the first chemotherapy cycle provides significant accuracy of the assessment. Association of the Procoag-PPL and MRI with the clinical risk assessment model for cancer-associated thrombosis in ambulatory patients with solid tumors (COMPASS-CAT RAM) further improved its accuracy.

Incidence and risk of thromboembolism associated with bevacizumab in patients with non-small cell lung carcinoma

Background

Bevacizumab, a recombinant humanized monoclonal antibody against vascular endothelial growth factor (VEGF), is effective for the treatment of advanced non-small cell lung cancer (NSCLC). However, severe adverse events (AEs) have been reported in NSCLC patients treated with bevacizumab. Currently, the contribution of Bevacizumab to thromboembolism is still controversial. We conducted a study to determine the overall risk and incidence of thromboembolism with bevacizumab in NSCLC patients.

Methods

Electronic databases such as the PubMed, Web of Science and Cochrane Library were searched for related trials. Statistical analyses were conducted to calculate the overall incidence rates, odds ratios (ORs), and 95% confidence intervals (CIs) by using either random-effect or fixed-effect models depending on the heterogeneity. We also used trial sequence analysis (TSA) to verify the pooled result.

Results

A total of 3,555 subjects from nine studies were included. The overall incidence of thromboembolism events in NSCLC patients treated with bevacizumab was 4.8% (95% CI: 1.9-7.7%). Without bevacizumab, this incidence was 2.9% (95% CI: 0.6-5.1%). Bevacizumab use was associated with a significantly increased risk in thromboembolism events (OR =1.74; 95% CI: 1.15-2.62; P=0.008). Subgroup analysis based on the doses showed that bevacizumab administered at 15 mg/kg (OR =1.81; 95% CI: 1.14-2.86; P=0.012), but not 7.5 mg/kg (OR =1.32; 95% CI: 0.78-2.24; P=0.296), increased the risk of thromboembolism.

Conclusions

Bevacizumab is associated with a significantly increased risk of thromboembolism development in NSCLC patients. It may have dose-toxicity relationship and low dose of bevacizumab may be a better choice for NSCLC patients, with equal efficacy and low hazard of thromboembolism events.

The relationship between tumor markers and pulmonary embolism in lung cancer

Background

Tumor markers (TMs) and D-Dimer are both hallmarks of severity and prognosis of lung cancer. Tumor markers could be related to pulmonary embolism (PE) in lung cancer.

Results

The number of abnormal tumor markers of lung cancer patients with pulmonary embolism (3.9 ± 1.1vs1.6 ± 0.6,P 0.005) was more than that in patients without pulmonary embolism. TMs panel (P trend < 0.001), CEA (R2 0.735, P0.003) and CYFRA21-1 (R2 0.718, P0.005) were positively correlated with D-Dimer in patients with pulmonary embolism. The multivariate logistic regression analysis showed that, for tumor markers, TMs panel (OR5.98, P < 0.001) had the strongest correlation with pulmonary embolism. The AUC (area under curve) of TMs panel and CEA were 0.82 [95%CI (0.71–0.95), P < 0.001] and 0.71 [95%CI (0.62–0.84), P 0.002] by ROC (receiver operating characteristic) curve analysis, respectively.

Materials and Methods

Tumor markers were compared between lung cancer patients complicated with pulmonary embolism and those without pulmonary embolism Then the correlation between each tumor marker as well as panel of combined TMs and D-Dimer as well as pulmonary embolism were analyzed for patients with pulmonary embolism.

Conclusions

There is a relationship between tumor markers and pulmonary embolism in patients with lung cancer. The panel of combined tumor markers is a valuable diagnostic marker for pulmonary embolism in lung cancer.

Risk factors and prognosis value of venous thromboembolism in patients with advanced non-small cell lung cancer: a case-control study

Background

Venous thromboembolism (VTE) is the well-known complication of cancer, especially among lung cancer patients. The objective of this study is to identify the incidence, risk factors and prognosis of VTE in the patients with non-small cell lung cancer (NSCLC) in an advanced or metastatic stage (stage III or IV). We hypothesized that NSCLC patients associated with VTE may lead to poor prognosis.

Methods

From 2012 to 2015, we retrospectively investigated 1,560 patients diagnosed with lung cancer in stage III or IV. Each VTE patient was matched with three control patients according to gender, age, pathology, clinical stage and the diagnosed time. Univariate and multivariate analyses were used in the study.

Results

Among the 1,560 patients in our study, 32 (2.0%) developed VTE in locally advanced or metastatic stage lung cancer. Weight loss, serous effusion, the absence of the EGFR mutation, poor performance status (PS), hypoalbuminemia, hyponatremia, long prothrombin time (PT), and elevated levels of C-reaction-protein (CRP) and D-dimer were found to be associated with an increased risk of VTE by univariate analyses. The multivariate analyses revealed that weight loss, poor PS, increased CRP and long PT were significantly related to VTE. Overall survival (OS) from diagnosis was significantly shorter in patients with VTE (medians 14.2 vs. 24.4 months; P<0.001).

Conclusions

The incidence of VTE was high among advanced NSCLC patients, particularly for those with weight loss, poor PS, increased CRP and long PT. Moreover, the patients with VTE complications may have a poorer prognosis.