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Ospina JP, Wen PY. Medical and neurologic management of brain tumor patients. Curr Opin Neurol 2024:00019052-990000000-00193. [PMID: 39221926 DOI: 10.1097/wco.0000000000001315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
PURPOSE OF REVIEW This article discusses commonly encountered medical and neurological complications in patients with brain tumors and highlights recommendations for their management based on updated evidence. RECENT FINDINGS Use of dexamethasone is correlated with worse prognosis in patients with glioblastoma, and in brain metastases, high doses may lead to increased side effects without additional clinical benefit. There are multiple antiseizure medications (ASM) to choose from and possible interactions and toxicity must be considered when choosing an agent. Additionally, there is growing interest in the use of AMPA receptor blockers as ASM in patients with brain tumors. Nonpharmacological strategies for the management of fatigue remain paramount. Cognitive decline is common after whole brain radiation (WBRT) and hippocampal-sparing WBRT results in superior cognitive outcomes. Venous thromboembolism is a common complication and there is growing evidence on the use of direct oral anticoagulants (DOACs) in this population. SUMMARY There is evolving evidence on the management of medical and neurological complications in patients with brain tumors. These complications, require early identification and multidisciplinary collaboration and expertise.
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Affiliation(s)
- Juan Pablo Ospina
- Center for Neuro-Oncology, Dana-Farber Cancer Institute
- Division of Neuro-Oncology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School
- Department of Neurology, Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute
- Division of Neuro-Oncology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School
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2
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Kapteijn MY, Bakker N, Koekkoek JAF, Versteeg HH, Buijs JT. Venous Thromboembolism in Patients with Glioblastoma: Molecular Mechanisms and Clinical Implications. Thromb Haemost 2024. [PMID: 39168144 DOI: 10.1055/s-0044-1789592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
Patients with glioblastoma are among the cancer patients with the highest risk of developing venous thromboembolism (VTE). Long-term thromboprophylaxis is not generally prescribed because of the increased susceptibility of glioblastoma patients to intracranial hemorrhage. This review provides an overview of the current clinical standard for glioblastoma patients, as well as the molecular and genetic background which underlies the high incidence of VTE. The two main procoagulant proteins involved in glioblastoma-related VTE, podoplanin and tissue factor, are described, in addition to the genetic aberrations that can be linked to a hypercoagulable state in glioblastoma. Furthermore, possible novel biomarkers and future treatment strategies are discussed, along with the potential of sequencing approaches toward personalized risk prediction for VTE. A glioblastoma-specific VTE risk stratification model may help identifying those patients in which the increased risk of bleeding due to extended anticoagulation is outweighed by the decreased risk of VTE.
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Affiliation(s)
- Maaike Y Kapteijn
- Division of Thrombosis and Hemostasis, Department of Medicine, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Nina Bakker
- Division of Thrombosis and Hemostasis, Department of Medicine, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henri H Versteeg
- Division of Thrombosis and Hemostasis, Department of Medicine, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen T Buijs
- Division of Thrombosis and Hemostasis, Department of Medicine, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Veiga VC, Peres SV, Ostolin TLVDP, Moraes FR, Belucci TR, Clara CA, Cavalcanti AB, Chaddad-Neto FEA, Batistella GNDR, Neville IS, Baeta AM, Yamada CAF. Incidence of venous thromboembolism and bleeding in patients with malignant central nervous system neoplasm: Systematic review and meta-analysis. PLoS One 2024; 19:e0304682. [PMID: 38900739 PMCID: PMC11189257 DOI: 10.1371/journal.pone.0304682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 05/16/2024] [Indexed: 06/22/2024] Open
Abstract
Central nervous system (CNS) malignant neoplasms may lead to venous thromboembolism (VTE) and bleeding, which result in rehospitalization, morbidity and mortality. We aimed to assess the incidence of VTE and bleeding in this population. METHODS This systematic review and meta-analysis (PROSPERO CRD42023423949) were based on a standardized search of PubMed, Virtual Health Library and Cochrane (n = 1653) in July 2023. After duplicate removal, data screening and collection were conducted by independent reviewers. The combined rates and 95% confidence intervals for the incidence of VTE and bleeding were calculated using the random effects model with double arcsine transformation. Subgroup analyses were performed based on sex, age, income, and type of tumor. Heterogeneity was calculated using Cochran's Q test and I2 statistics. Egger's test and funnel graphs were used to assess publication bias. RESULTS Only 36 studies were included, mainly retrospective cohorts (n = 30, 83.3%) from North America (n = 20). Most studies included were published in high-income countries. The sample size of studies varied between 34 and 21,384 adult patients, mostly based on gliomas (n = 30,045). For overall malignant primary CNS neoplasm, the pooled incidence was 13.68% (95%CI 9.79; 18.79) and 11.60% (95%CI 6.16; 18.41) for VTE and bleeding, respectively. The subgroup with elderly people aged 60 or over had the highest incidence of VTE (32.27% - 95%CI 14.40;53.31). The studies presented few biases, being mostly high quality. Despite some variability among the studies, we observed consistent results by performing sensitivity analysis, which highlight the robustness of our findings. CONCLUSIONS Our study showed variability in the pooled incidence for both overall events and subgroup analyses. It was highlighted that individuals over 60 years old or diagnosed with GBM had a higher pooled incidence of VTE among those with overall CNS malignancies. It is important to note that the results of this meta-analysis refer mainly to studies carried out in high-income countries. This highlights the need for additional research in Latin America, and low- and middle-income countries.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Alex M. Baeta
- BP–A Beneficência Portuguesa de São Paulo, São Paulo, Brasil
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Mahé I, Frère C, Pernod G, Sanchez O, Baih AI. [Translation into French and republication of: "Management of venous thromboembolic disease in patients with malignant brain tumours"]. Rev Med Interne 2024; 45:300-311. [PMID: 38763817 DOI: 10.1016/j.revmed.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 05/21/2024]
Abstract
This article addresses the management of venous thromboembolism in patients with malignant brain tumours, including both primary and secondary (metastatic) tumours. The available data on patients on venous thromboembolism recurrence and bleeding risks in patients with brain tumours is limited, since these patients have been excluded from most randomised, interventional, head-to-head, clinical trials comparing low molecular weight heparins to vitamin K antagonists or to direct oral factor Xa inhibitors. More information is available from retrospective observational studies, which however were generally small, and carried a high risk of confounding. Their findings suggest that direct factor Xa inhibitor use is associated with lower rates of intracranial haemorrhage compared with low molecular weight heparins. Overall, the safety profile of direct oral factor Xa inhibitors when used to prevent venous thromboembolism recurrence in patients with either primary or secondary brain tumours appears to be favourable. The available data are in favour of using an anticoagulant at a full therapeutic dose in patients with primary and secondary brain tumours experiencing a venous thromboembolism, although they are not yet sufficiently robust to permit recommending a direct factor Xa inhibitor over low-molecular weight heparin.
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Affiliation(s)
- I Mahé
- Service de médecine interne, hôpital Louis-Mourier, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE Network, Saint-Étienne, France.
| | - C Frère
- Hôpital de la Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, Sorbonne université, Inserm UMRS 1166, GRC 27 Greco, DMU BioGeMH, Paris, France
| | - G Pernod
- F-CRIN INNOVTE Network, Saint-Étienne, France; Service de médecine vasculaire, université Grenoble-Alpes, Grenoble, France
| | - O Sanchez
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE Network, Saint-Étienne, France; Service de pneumologie et soins intensifs, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France
| | - A Id Baih
- Service de neuro-oncologie, Institut du cerveau - Paris Brain Institute, ICM, hôpitaux universitaires La Pitié-Salpêtrière - Charles-Foix, DMU Neurosciences, Sorbonne université, Assistance publique-Hôpitaux de Paris, Inserm, CNRS, Paris, France
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Carpentier A, Stupp R, Sonabend AM, Dufour H, Chinot O, Mathon B, Ducray F, Guyotat J, Baize N, Menei P, de Groot J, Weinberg JS, Liu BP, Guemas E, Desseaux C, Schmitt C, Bouchoux G, Canney M, Idbaih A. Repeated blood-brain barrier opening with a nine-emitter implantable ultrasound device in combination with carboplatin in recurrent glioblastoma: a phase I/II clinical trial. Nat Commun 2024; 15:1650. [PMID: 38396134 PMCID: PMC10891097 DOI: 10.1038/s41467-024-45818-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Here, the results of a phase 1/2 single-arm trial (NCT03744026) assessing the safety and efficacy of blood-brain barrier (BBB) disruption with an implantable ultrasound system in recurrent glioblastoma patients receiving carboplatin are reported. A nine-emitter ultrasound implant was placed at the end of tumor resection replacing the bone flap. After surgery, activation to disrupt the BBB was performed every four weeks either before or after carboplatin infusion. The primary objective of the Phase 1 was to evaluate the safety of escalating numbers of ultrasound emitters using a standard 3 + 3 dose escalation. The primary objective of the Phase 2 was to evaluate the efficacy of BBB opening using magnetic resonance imaging (MRI). The secondary objectives included safety and clinical efficacy. Thirty-three patients received a total of 90 monthly sonications with carboplatin administration and up to nine emitters activated without observed DLT. Grade 3 procedure-related adverse events consisted of pre syncope (n = 3), fatigue (n = 1), wound infection (n = 2), and pain at time of device connection (n = 7). BBB opening endpoint was met with 90% of emitters showing BBB disruption on MRI after sonication. In the 12 patients who received carboplatin just prior to sonication, the progression-free survival was 3.1 months, the 1-year overall survival rate was 58% and median overall survival was 14.0 months from surgery.
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Affiliation(s)
- Alexandre Carpentier
- Sorbonne Université, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurochirurgie, Paris, France.
| | - Roger Stupp
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Northwestern Medicine Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Adam M Sonabend
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Northwestern Medicine Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Henry Dufour
- Aix-Marseille Univ, APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service de Neuro-Oncologie, Marseille, France
| | - Olivier Chinot
- Aix-Marseille Univ, APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service de Neuro-Oncologie, Marseille, France
| | - Bertrand Mathon
- Sorbonne Université, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurochirurgie, Paris, France
| | - François Ducray
- Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Service de Neuro-Oncologie, Hospices Civils de Lyon, Cancer Research Center of Lyon, INSERM U1052, CNRS UMR 5286, Cancer Cell Plasticity Department, Lyon, France
| | - Jacques Guyotat
- Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Service de Neuro-Oncologie, Hospices Civils de Lyon, Cancer Research Center of Lyon, INSERM U1052, CNRS UMR 5286, Cancer Cell Plasticity Department, Lyon, France
| | | | | | - John de Groot
- Departments of Neurology and Neurosurgery, University of California, San Francisco, CA, USA
| | - Jeffrey S Weinberg
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Benjamin P Liu
- Departments of Radiology and Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | | | | | | | - Ahmed Idbaih
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau, ICM, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neuro-Oncologie, Paris, France
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Mahé I, Frère C, Pernod G, Sanchez O, Id Baih A. Management of venous thromboembolic disease in patients with malignant brain tumours. Arch Cardiovasc Dis 2024; 117:60-71. [PMID: 38087664 DOI: 10.1016/j.acvd.2023.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
This article addresses the management of venous thromboembolism in patients with malignant brain tumours, including both primary and secondary (metastatic) tumours. The available data on patients on venous thromboembolism recurrence and bleeding risks in patients with brain tumours is limited, since these patients have been excluded from most randomised, interventional, head-to-head, clinical trials comparing low molecular weight heparins to vitamin K antagonists or to direct oral Factor Xa inhibitors. More information is available from retrospective observational studies, which however were generally small, and carried a high risk of confounding. Their findings suggest that direct Factor Xa inhibitor use is associated with lower rates of intracranial haemorrhage compared with low molecular weight heparins. Overall, the safety profile of direct oral Factor Xa inhibitors when used to prevent venous thromboembolism recurrence in patients with either primary or secondary brain tumours appears to be favourable. The available data are in favour of using an anticoagulant at a full therapeutic dose in patients with primary and secondary brain tumours experiencing a venous thromboembolism, although they are not yet sufficiently robust to permit recommending a direct Factor Xa inhibitor over low-molecular weight heparin.
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Affiliation(s)
- Isabelle Mahé
- Service de médecine interne, Hôpital Louis-Mourier, AP-HP, 178, rue des Renouillers, 92700 Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France.
| | - Corinne Frère
- Hôpital de la Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, Sorbonne université, Inserm UMRS 1166, GRC 27 GRECO, DMU BioGeMH, Paris, France
| | - Gilles Pernod
- Service de médecine vasculaire,Université Grenoble-Alpes, Grenoble, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Olivier Sanchez
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de Pneumologie et soins intensifs, hôpital européen Georges Pompidou, APHP, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Ahmed Id Baih
- Sorbonne Université, AP-HP, Institut du Cerveau - Paris Brain Institute, ·ICM, Inserm, CNRS, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, DMU Neurosciences, Service de Neuro-Oncologie, Paris, France
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Yang Y, Hu F, Wu S, Huang Z, Wei K, Ma Y, Ou-Yang Q. Blood-based biomarkers: diagnostic value in brain tumors (focus on gliomas). Front Neurol 2023; 14:1297835. [PMID: 37936915 PMCID: PMC10626008 DOI: 10.3389/fneur.2023.1297835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/02/2023] [Indexed: 11/09/2023] Open
Abstract
Background Brain tumors, especially gliomas, are known for high lethality. It is currently understood that the correlations of tumors with coagulation and inflammation have been gradually revealed. Objective This study aimed to explore the potential value of several reported peripheral blood parameters as comprehensively as possible, with preoperative diagnosis and identification of brain tumors (focus on gliomas). Methods Patients with central nervous system tumors (craniopharyngioma, ependymoma, spinal meningioma, acoustic neuroma, brain metastases, meningioma, and glioma) or primary trigeminal neuralgia admitted to our hospital were retrospectively analyzed. The results of the routine coagulation factor test, serum albumin test, and blood cell test in peripheral blood were recorded for each group of patients on admission. Neutrophil-lymphocyte ratio (NLR), derived NLR (dNLR), platelet-lymphocyte ratio (PLR), lymphocyte-monocyte ratio (LMR), prognostic nutritional index (PNI), the systemic immune-inflammation index (SII), pan-immune-inflammation value (PIV), and their pairings were calculated. Their ability to identify brain tumors and their correlation with glioma grade were analyzed. Results A total of 698 patients were included in this retrospective case-control study. Glioma patients had higher NLR, SII, and PIV but lower LMR. The NLR in the brain metastasis group was lower than that in the control, meningioma, and acoustic neuroma groups, but the SII and PIV were higher than those in the ependymoma group. Fibrinogen, white blood cell count, neutrophil count, NLR, SII, and PIV in the GBM group were higher than those in the control group. In all comparisons, NLR and NLR + dNLR showed the greatest accuracy, with areas under the curve (AUCs) of 0.7490 (0.6482-0.8498) and 0.7481 (0.6457-0.8505), respectively. PIV, dNLR + PIV, and LMR + PIV ranked second, with AUCs of 0.7200 (0.6551-0.7849), 0.7200 (0.6526-0.7874), 0.7204 (0.6530-0.7878) and 0.7206 (0.6536-0.7875), respectively. Conclusion NLR, PIV, and their combinations show high sensitivity and specificity in the diagnosis of brain tumors, especially gliomas. Overall, our results provide evidence for these convenient and reliable peripheral blood markers.
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Affiliation(s)
- Yuting Yang
- Institute of Biomedical Engineering, College of Medicine, Southwest Jiaotong University, Chengdu, Sichuan, China
- Department of Neurosurgery, Affiliated Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Fei Hu
- Department of Neurosurgery, Affiliated Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Song Wu
- Department of Neurosurgery, Affiliated Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Zhangliang Huang
- Institute of Biomedical Engineering, College of Medicine, Southwest Jiaotong University, Chengdu, Sichuan, China
- Department of Neurosurgery, Affiliated Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Kun Wei
- Department of Neurosurgery, Affiliated Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Yuan Ma
- Institute of Biomedical Engineering, College of Medicine, Southwest Jiaotong University, Chengdu, Sichuan, China
- Department of Neurosurgery, Affiliated Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Qing Ou-Yang
- Department of Neurosurgery, Affiliated Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
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Jo J, Diaz M, Horbinski C, Mackman N, Bagley S, Broekman M, Rak J, Perry J, Pabinger I, Key NS, Schiff D. Epidemiology, biology, and management of venous thromboembolism in gliomas: An interdisciplinary review. Neuro Oncol 2023; 25:1381-1394. [PMID: 37100086 PMCID: PMC10398809 DOI: 10.1093/neuonc/noad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Patients with diffuse glioma are at high risk of developing venous thromboembolism (VTE) over the course of the disease, with up to 30% incidence in patients with glioblastoma (GBM) and a lower but nonnegligible risk in lower-grade gliomas. Recent and ongoing efforts to identify clinical and laboratory biomarkers of patients at increased risk offer promise, but to date, there is no proven role for prophylaxis outside of the perioperative period. Emerging data suggest a higher risk of VTE in patients with isocitrate dehydrogenase (IDH) wild-type glioma and the potential mechanistic role of IDH mutation in the suppression of production of the procoagulants tissue factor and podoplanin. According to published guidelines, therapeutic anticoagulation with low molecular weight heparin (LMWH) or alternatively, direct oral anticoagulants (DOACs) in patients without increased risk of gastrointestinal or genitourinary bleeding is recommended for VTE treatment. Due to the elevated risk of intracranial hemorrhage (ICH) in GBM, anticoagulation treatment remains challenging and at times fraught. There are conflicting data on the risk of ICH with LMWH in patients with glioma; small retrospective studies suggest DOACs may convey lower ICH risk than LMWH. Investigational anticoagulants that prevent thrombosis without impairing hemostasis, such as factor XI inhibitors, may carry a better therapeutic index and are expected to enter clinical trials for cancer-associated thrombosis.
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Affiliation(s)
- Jasmin Jo
- Department of Internal Medicine, Division of Hematology and Oncology, East Carolina University, Greenville, NC, USA
| | - Maria Diaz
- Department of Neurology, Division of Neuro-Oncology, Columbia University, New York, NY, USA
| | - Craig Horbinski
- Department of Pathology, Northwestern University, Chicago, IL, USA
| | - Nigel Mackman
- Department of Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Stephen Bagley
- Department of Medicine, University of Pennsylvania, Philadelphia PA, USA
| | - Marika Broekman
- Department of Neurosurgery, University Medical Center, Utrecht, The Netherlands
| | - Janusz Rak
- Department of Pediatrics, McGill University, Montreal, Canada
| | - James Perry
- Department of Neurology, Sunnybrook Health Sciences Center, Toronto, Canada
| | - Ingrid Pabinger
- Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Nigel S Key
- Department of Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - David Schiff
- Department of Neurology, Division of Neuro-Oncology, University of Virginia, Charlottesville, VA, USA
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Yang J, He Z, Li M, Hong T, Ouyang T. Risk of intracranial hemorrhage with direct oral anticoagulation versus low molecular weight heparin in the treatment of brain tumor-associated venous thromboembolism: A meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107243. [PMID: 37413715 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107243] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVES Direct oral anticoagulants (DOACs) are effective in treating cancer-related thrombosis and are superior to low molecular weight heparin (LMWH) in terms of efficacy. The effects of DOACs or LMWH on intracranial hemorrhage (ICH) remain uncertain in individuals with brain tumors. We conducted a meta-analysis to compare the frequency of ICH in individuals with brain tumors treated with DOACs or LMWH. METHODS Two independent investigators reviewed all studies that compared the frequency of ICH in patients with brain tumors who received DOACs or LMWH. The primary outcome was the incidence of ICH. We used the Mantel-Haenszel method to estimate the combined effect and calculated 95% confidence intervals (CI). RESULTS This study encompassed six articles. The results indicated that cohorts treated with DOAC experienced much fewer instances of ICH compared to the LMWH cohorts (relative risk [RR] 0.39; 95% CI 0.23-0.65; P = 0.0003; I2 = 0%). The same effect was observed for the prevalence of major ICH (RR 0.34; 95% CI 0.12-0.97; P = 0.04; I2 = 0%), but there was no difference for fatal ICH. Subgroup analysis indicated that DOACs had a substantially reduced incidence of ICH in primary brain tumors (RR 0.18; 95% CI 0.06-0.50; P = 0.001; I2 = 0%), but had no impact on ICH with secondary brain tumors. CONCLUSIONS This meta-analysis showed that DOACs are associated with a lower risk of ICH than LMWH therapy in treating venous thromboembolism associated with brain tumors, especially in patients with primary brain tumors.
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Affiliation(s)
- Jun Yang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Jiangxi Province, China.
| | - Zesong He
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Jiangxi Province, China.
| | - Meihua Li
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Jiangxi Province, China.
| | - Tao Hong
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Jiangxi Province, China.
| | - Taohui Ouyang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Jiangxi Province, China.
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Kaye B, Ali A, Correa Bastianon Santiago RA, Ibrahim B, Isidor J, Awad H, Sabahi M, Obrzut M, Adada B, Ranjan S, Borghei-Razavi H. The Role of EGFR Amplification in Deep Venous Thrombosis Occurrence in IDH Wild-Type Glioblastoma. Curr Oncol 2023; 30:4946-4956. [PMID: 37232831 DOI: 10.3390/curroncol30050373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/25/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction: Glioblastoma (GBM) patients have a 20-30 incidence of venous thromboembolic events. EGFR is a widely used prognostic marker for many cancers. Recent lung cancer studies have described relationships between EGFR amplification and an increased incidence of thromboembolic complications. We aim to explore this relationship in glioblastoma patients. Methods: Two hundred ninety-three consecutive patients with IDH wild-type GBM were included in the analysis. The amplification status of EGFR was measured using fluorescence in situ hybridization (FISH). Centromere 7 (CEP7) expression was recorded to calculate the EGFR-to-CEP7 ratio. All data were collected retrospectively through chart review. Molecular data were obtained through the surgical pathology report at the time of biopsy. Results: There were 112 subjects who were EGFR-amplified (38.2%) and 181 who were non-amplified (61.8%). EGFR amplification status was not significantly correlated with VTE risk overall (p = 0.2001). There was no statistically significant association between VTE and EGFR status after controlling for Bevacizumab therapy (p = 0.1626). EGFR non-amplified status was associated with an increased VTE risk in subjects greater than 60 years of age (p = 0.048). Conclusions: There was no significant difference in occurrence of VTE in patients with glioblastoma, regardless of EGFR amplification status. Patients older than 60 years of age with EGFR amplification experienced a lower rate of VTE, contrary to some reports on non-small-cell lung cancer linking EGFR amplification to VTE risk.
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Affiliation(s)
- Brandon Kaye
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL 33328, USA
| | - Assad Ali
- Cleveland Clinic Florida, Department of Neurosurgery, Weston, FL 33331, USA
| | | | - Bilal Ibrahim
- Cleveland Clinic Florida, Department of Neurosurgery, Weston, FL 33331, USA
| | - Julio Isidor
- Cleveland Clinic Florida, Department of Neurosurgery, Weston, FL 33331, USA
| | - Hany Awad
- Cleveland Clinic Florida, Department of Neurosurgery, Weston, FL 33331, USA
| | | | - Michal Obrzut
- Cleveland Clinic Florida, Department of Neurosurgery, Weston, FL 33331, USA
| | - Badih Adada
- Cleveland Clinic Florida, Department of Neurosurgery, Weston, FL 33331, USA
| | - Surabhi Ranjan
- Cleveland Clinic Florida, Department of Neurosurgery, Weston, FL 33331, USA
| | | |
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