Unsuspected pulmonary emboli adversely impact survival in patients with cancer undergoing routine staging multi-row detector computed tomography scanning

Rivaroxaban treatment for asymptomatic venous thromboembolism: insights from the J'xactly study

BACKGROUND

An established treatment strategy for asymptomatic pulmonary embolism (PE) or deep vein thrombosis (DVT) remains uncertain in Japan; therefore, in this study, we clarify the characteristics and outcomes of symptomatic compared to asymptomatic patients with PE or DVT.

METHODS

This prospective, multicenter sub-analysis of the J'xactly study in Japan included 1,016 patients (mean age, 68; 41% male) with venous thromboembolism (VTE) treated with rivaroxaban.

RESULTS

Asymptomatic PE patients (47% of PE patients) were more likely to have active cancer and asymptomatic proximal DVT at lower severity than symptomatic PE patients, despite no differences in age, sex, or the proportion receiving intensive 30 mg/day-rivaroxaban. Patients with asymptomatic DVT (34% of DVT patients) were older, had higher rates of female sex, active cancer, and distal DVT, and received shorter, less intense rivaroxaban treatment. Incidences did not differ between asymptomatic and symptomatic PE patients for recurrent symptomatic VTE (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.22-1.62; P = 0.31) or major bleeding (HR, 0.68; 95% CI, 0.20-2.33; P = 0.58), nor between asymptomatic and symptomatic DVT patients for recurrent symptomatic VTE (HR, 0.56; 95% CI, 0.23-1.40; P = 0.21) and major bleeding (HR, 1.47; 95% CI, 0.54-3.97; P = 0.45).

CONCLUSIONS

The real-world composite adverse event rate for treatment with rivaroxaban, as physician-adjusted for dose and duration, was similar for asymptomatic and symptomatic patients regardless of the presence of PE or DVT, suggesting a favorable safety profile for potential rivaroxaban treatment for asymptomatic VTE.

Unreported incidental pulmonary embolism in patients with cancer: Radiologic natural history and risk of recurrent venous thromboembolism and death

PURPOSE

To assess the risk of recurrent venous thromboembolism (VTE) and death in patients with unreported cancer-associated incidental pulmonary embolism (iPE).

MATERIALS AND METHODS

Matched cohort study on cancer patients with a CT study including the chest between 2014-01-01 and 2019-06-30. Studies were reviewed for unreported iPE, and cases were matched with controls without iPE. Cases and controls were followed for one year, with recurrent VTE and death as outcome events.

RESULTS

Of the included 2960 patients, 171 patients had unreported and untreated iPE. While controls had a one-year VTE risk of 8.2 events per 100 person-years, cases with a single subsegmental iPE had a recurrent VTE risk of 20.9 events, and between 52.0 and 72.0 events per 100 person-years for multiple subsegmental iPE and more proximal iPE. In multivariable analysis, multiple subsegmental and more proximal iPE were significantly associated with the risk of recurrent VTE, while single subsegmental iPE was not associated with the risk of recurrent VTE (p = 0.13). In the subgroup of patients (n = 47) with cancer not in the highest Khorana VTE risk category, no metastases and up to three involved vessels, recurrent VTE occurred in two patients (4.7 cases per 100 person-years). There were no significant associations between iPE burden and risk of death.

CONCLUSION

In cancer patients with unreported iPE, iPE burden was associated with the risk of recurrent VTE. However, having a single subsegmental iPE was not associated with the risk of recurrent VTE. There were no significant associations between iPE burden and risk of death.

Incidentally Diagnosed With Pulmonary Embolism in Lung Cancer Patients: Comparison of Clinical Characteristics and Mortality With Symptomatic Pulmonary Embolism

The purpose of this work was to compare the clinical characteristics, rate of recurrent venous thromboembolism (VTE), bleeding complications and mortality of incidental and symptomatic pulmonary embolism (PE) detected on computed tomography in patients with lung cancer. Clinical data of lung cancer patients with PE were obtained from the Department of Respiratory and Critical Care Medicine of Ningbo First affiliated hospital of Ningbo University during January 2016 and June 2021 and were reviewed retrospectively. We compared clinical and radiological characteristics in lung cancer patients with incidental PE (IPE) and symptomatic PE (SPE) and identified variables associated with the 1-year survival on multivariate Cox analysis. All patients were followed up for 1 year to compare the risks of recurrent VTE, bleeding complications, and mortality. Survival analysis was performed by use of Kaplan-Meier. A total of 223 lung cancer patients with PE were enrolled over the period. Of these, 117 (52%) patients had symptomatic whereas 106 (48%) patients had incidental PE. Those with IPE were more likely to have adenocarcinoma, VTE history, chronic respiratory disease and chemotherapy within 30 days prior to PE, while SPE was more frequently observed in patients with squamous cancer, concomitant VTE, performance status 0-1, chronic heart disease and major surgery within 30 days prior to PE. During 1 year of follow-up, recurrent VTE was diagnosed in 10 patients (9.3%) in lung cancer patients with IPE and 13 patients (11.2%) with SPE. The 12-month cumulative recurrent VTE incidence was 9.6% for patients with incidental and 11.4% for patients with symptomatic PE (P = .61). The 12-month cumulative incidences of major bleeding complications were also comparable in the 2 groups (8.1% for incidental patients and 9.8% for symptomatic patients; P = .62). However, the respective 12-month mortality risks were 34.6% and 30.2% in lung cancer patients with IPE and SPE respectively (P = .03). On multivariate Cox analysis, we found that IPE occurrence was an independent risk factor associated with 1-year mortality in lung cancer patients complicated with PE after adjusting for age and sex (HR 1.517; 95% CI: 1.366-1.684; P = .027). Our findings suggest that lung cancer patients diagnosed with and treated for incidental PE had a similar rate of recurrent VTE, and incidence of hemorrhagic complications, but a significantly higher 1-year cumulative mortality rate after PE compared to those with symptomatic PE. IPE may be a marker of poor prognosis.

Detection of Incidental Pulmonary Embolism on Conventional Contrast-Enhanced Chest CT: Comparison of an Artificial Intelligence Algorithm and Clinical Reports

BACKGROUND. Artificial intelligence (AI) algorithms have shown strong performance for detection of pulmonary embolism (PE) on CT examinations performed using a dedicated protocol for PE detection. AI performance is less well studied for detecting PE on examinations ordered for reasons other than suspected PE (i.e., incidental PE [iPE]). OBJECTIVE. The purpose of this study was to assess the diagnostic performance of an AI algorithm for detection of iPE on conventional contrast-enhanced chest CT examinations. METHODS. This retrospective study included 2555 patients (mean age, 53.2 ± 14.5 [SD] years; 1340 women, 1215 men) who underwent 3003 conventional contrast-enhanced chest CT examinations (i.e., not using pulmonary CTA protocols) between September 2019 and February 2020. A commercial AI algorithm was applied to the images to detect acute iPE. A vendor-supplied natural language processing (NLP) algorithm was applied to the clinical reports to identify examinations interpreted as positive for iPE. For all examinations that were positive by the AI-based image review or by NLP-based report review, a multireader adjudication process was implemented to establish a reference standard for iPE. Images were also reviewed to identify explanations of AI misclassifications. RESULTS. On the basis of the adjudication process, the frequency of iPE was 1.3% (40/3003). AI detected four iPEs missed by clinical reports, and clinical reports detected seven iPEs missed by AI. AI, compared with clinical reports, exhibited significantly lower PPV (86.8% vs 97.3%, p = .03) and specificity (99.8% vs 100.0%, p = .045). Differences in sensitivity (82.5% vs 90.0%, p = .37) and NPV (99.8% vs 99.9%, p = .36) were not significant. For AI, neither sensitivity nor specificity varied significantly in association with age, sex, patient status, or cancer-related clinical scenario (all p > .05). Explanations of false-positives by AI included metastatic lymph nodes and pulmonary venous filling defect, and explanations of false-negatives by AI included surgically altered anatomy and small-caliber subsegmental vessels. CONCLUSION. AI had high NPV and moderate PPV for iPE detection, detecting some iPEs missed by radiologists. CLINICAL IMPACT. Potential applications of the AI tool include serving as a second reader to help detect additional iPEs or as a worklist triage tool to allow earlier iPE detection and intervention. Various explanations of AI misclassifications may provide targets for model improvement.

Cancer patients' experiences of the diagnosis and treatment of incidental pulmonary embolism (a qualitative study)

BACKGROUND

The diagnosis of symptomatic cancer-associated thrombosis often causes distress and alarm for patients, especially for those unaware of the risk, or the signs and symptoms to look out for. There are few data about cancer patients' experiences of incidentally diagnosed pulmonary embolism (IPE), where lack of warning (recognised signs, symptoms) may cause delayed diagnosis and aggravate distress.

OBJECTIVES

To explore cancer patients' experience of the diagnosis of and living with incidental pulmonary embolism treated with anticoagulation.

METHODS

A qualitative study using modified grounded theory approach. Semi-structured interviews were conducted as part of a mixed- methods prospective observational survey study of consenting patients with IPE. Data were subjected to thematic analysis. The qualitative findings are presented.

FINDINGS

Eleven participants were interviewed (mean age 68.3 years, range 38-82 years; various forms of cancer and stages). Three major themes and one cross-cutting theme were generated. Theme (1): IPE is experienced in the context of cancer and concomitant comorbidities. Issues are understood in the shadow of-and often overshadowed by-current serious illness. Theme (2): Being diagnosed with IPE. Misattribution to cancer or other comorbidities caused delay in help-seeking and diagnosis. Theme (3): Coping with anticoagulation. Participants' incorporated anticoagulation treatment and its effects into their daily routine with acceptance and stoicism. Finally, the cross-cutting theme relates to a lack of information and uncertainty, contributing to distress throughout the experience.

CONCLUSION

The diagnosis of IPE was upsetting and unexpected. Expert and timely information was valued by those with IPE. Education called for about the increased risk of cancer-associated thrombosis and the signs and symptoms to be aware of.

Pulmonary Embolism in the Cancer Associated Thrombosis Landscape

In cancer patients, pulmonary embolism (PE) is the second leading cause of death after the cancer itself, most likely because of difficulties in diagnosing the disease due to its nonclassical presentation. The risk of PE recurrence and possibly the case-fatality rate depends on whether the patient presents a symptomatic PE, an unsuspected PE, a subsegmental PE, or a catheter-related PE. Choosing the best therapeutic option is challenging and should consider the risk of both the recurrence of thrombosis and the occurrence of bleeding. The purpose of this review is to provide an overview of the clinical characteristics and the treatment of cancer-associated PE, which could benefit clinicians to better manage the deadliest form of thrombosis associated with cancer. After a brief presentation of the epidemiological data, we will present the current attitude towards the diagnosis and the management of cancer patients with PE. Finally, we will discuss the perspectives of how the medical community can improve the management of this severe medical condition.

Thromboembolic Events Burden in Patients With Solid Tumors and Their Predisposing Factors

Introduction: The relationship between cancers and thromboembolic events is well established. In our study, we aim to determine the burden of thromboembolic events in patients with solid tumors and identify the risk factors related to their development.

Materials & Methods: Data on patients with solid tumors and thromboembolism between January 2013 and September 2014 were collected and analyzed.

Results: During the study period 174 patients were identified. Of which, 172 (98.9%) had venous thrombus embolism, 137 (79%) were diagnosed with deep vein thromboses, 67 (38.5%) with pulmonary embolism, 84 (48.3%) were symptomatic and 90 (51.7) were incidental at diagnosis. The most common patients and disease characteristics were female sex, high body mass index (BMI), metastatic stage, colorectal and breast primaries, and anti-neoplastic therapy.

Conclusion: Our study confirmed the high burden of thromboembolic events in cancer patients and the relevant factors associated with its development.

Prognostic Performance of Hestia Criteria in Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis

Previous studies have suggested that Hestia criteria could effectively identifying patients with acute pulmonary embolism (PE) who were at low risk of mortality for outpatient treatment or early discharge. But the performance of Hestia criteria in stratifying patients at different risk class is still unknown. We sought to comprehensively evaluate the prognostic impact of Hestia criteria for PE. The literatures search was conducted in PubMed, Web of Science and EMBASE from 1 August 2011 to 31 October 2021. Finally, Eight studies with 4110 patients were included in our meta-analysis. Overall, the pool percentage of patients classified as low-risk group and high-risk group were 41.4%% and 58.6% respectively, and the all-course mortality rates of each group were 2.3% and 10.6%, respectively. The pooled rate of PE-related composite adverse outcomes in high-risk group was increasingly higher than in low-risk group (15.7% vs 4.4%). High risk group was also markedly associated with overall mortality (OR: 7.21, 95%CI: 4.96-10.46, p < 0.00001), and PE-related adverse outcomes (OR:5.38, 95% CI:3.95-7.32, p < 0.00001). The pooled sensitivity, specificity, PLR, NLR of Hestia criteria for overall mortality were 0.90 (95% CI:0.83-0.94), 0.43 (95% CI:0.31-0.55), 1.6 (95% CI:1.3-1.9), 0.23 (95% CI: 0.15-0.35), respectively. The area under SROC curve (AUC) was 0.81 (95% CI: 0.77-0.84). The result of our meta-analysis indicate that Hestia criteria can effectively identify PE patients at low risk of poor prognosis with high sensitivity and NPV, but its prognostic role in patients with higher risk class still need to be verified.

Concurrence of Gastric Cancer and Incidental Pulmonary Embolism May Be a Prognostic Factor for Advanced Gastric Cancer Patients with Incidental Pulmonary Embolism

Objective

Cancer is well known as the most important risk factor for the emergence of pulmonary embolism (PE). The incidence of incidental PE (IPE) has increased with widely use of multi-detector-row computed tomography (CT) technology. Simultaneously, more new cancer patients diagnosed concomitantly with IPE are found. No study has examined the presentation and prognosis of incidental pulmonary embolism (IPE) in gastric cancer patients. The aim of this study was to analyse prognostic factors in patients with advanced gastric cancer complicated with IPE.

Patients and Methods

Ninety patients with histologically confirmed advanced gastric adenocarcinoma diagnosed with IPE were enrolled. Continuous variables were compared using Student’s t-test or the Mann–Whitney U-test if non-normally distributed. The Chi-squared test (or Fisher’s exact test where appropriate) was used to compare categorical variables. The Kaplan–Meier method and the Log rank test were used for survival analysis. Independent prognostic factors for survival were determined using a Cox proportional hazards model. A two-sided P-value < 0.05 was considered statistically significant.

Results

Nineteen patients were diagnosed with IPE concomitantly with gastric cancer. Concurrence of gastric cancer and IPE, lack of anticoagulation therapy, and location of IPE were associated with survival. After adjusting for age and sex, the concurrence of gastric cancer and IPE, lack of anticoagulation, and central IPE independently influenced the survival of advanced gastric cancer patients with IPE. Subgroup analysis of patients with peripheral pulmonary embolisms confirmed that anticoagulant therapy provided a survival benefit.

Conclusion

Concurrence of gastric cancer and IPE may be a prognostic factor for advanced gastric cancer patients with IPE.

Clinical characteristics, management, and outcome of incidental pulmonary embolism in cancer patients

Incidental pulmonary embolisms (IPEs) are common in cancer patients. Examining the characteristics and outcomes of IPEs in cancer patients can help to ensure proper management, promoting better outcomes. To determine the clinical characteristics, management, and outcomes of IPEs for cancer patients, we conducted a 1:2 ratio case-control study and identified all consecutive patients with IPE who visited the emergency department at The University of Texas MD Anderson Cancer Center between 1 January 2006 and 1 January 2016. Each IPE case was matched with 2 controls using a propensity score obtained using logistic regression for IPE status with other factors affecting overall survival. A total of 904 confirmed cases were included in the analysis. IPE frequently occurred during the first year after cancer diagnosis (odds ratio [OR], 2.79; 95% confidence interval [95% CI], 2.37-3.29; P < .001). Patients receiving cytotoxic chemotherapy had a nearly threefold greater risk of developing IPE (OR, 2.87; 95% CI, 2.42-3.40; P < .001). In-hospital mortality was 1.9%. The 7- and 30-day mortality rates among the cases were 1.8% and 9.9%, respectively, which was significantly higher than in the control groups: 0.2% and 3.1%, respectively (P < .001). IPE was associated with reduced overall survival (hazard ratio [HR], 1.93; 95% CI, 1.74-2.14; P < .001). Concurrent incidental venous thromboembolism was identified in 189 of the patients (20.9%) and was also associated with reduced overall survival (HR, 1.65; 95% CI, 1.21-2.25; P = .001). Our results show that IPE events are associated with poor outcomes in cancer patients. Proper management plans similar to those of symptomatic pulmonary embolisms are essential.

Missed Incidental Pulmonary Embolism: Harnessing Artificial Intelligence to Assess Prevalence and Improve Quality Improvement Opportunities

PURPOSE

Incidental pulmonary embolism (IPE) can be found on body CT. The aim of this study was to evaluate the feasibility of using artificial intelligence to identify missed IPE on a large number of CT examinations.

METHODS

This retrospective analysis included all single-phase chest, abdominal, and pelvic (CAP) and abdominal and pelvic (AP) CT examinations performed at a single center over 1 year, for indications other than identification of PE. Proprietary visual classification and natural language processing software was used to analyze images and reports from all CT examinations, followed by a two-step human adjudication process to classify cases as true positive, false positive, true negative, or false negative. Descriptive statistics were assessed for prevalence of IPE and features (subsegmental versus central, unifocal versus multifocal, right heart strain or not) of missed IPE. Interrater agreement for radiologist readers was also calculated.

RESULTS

A total of 11,913 CT examinations (6,398 CAP, 5,515 AP) were included. Thirty false-negative examinations were identified on CAP (0.47%; 95% confidence interval [CI], 0.32%-0.67%) and nineteen false-negative studies on AP (0.34%; 95% CI, 0.21%-0.54%) studies. During manual review, readers showed substantial agreement for identification of IPE on CAP (κ = 0.76; 95% CI, 0.66-0.86) and nearly perfect agreement for identification of IPE on AP (κ = 0.86; 95% CI, 0.76-0.97). Forty-nine missed IPEs (0.41%; 95% CI, 0.30%-0.54%) were ultimately identified, compared with seventy-nine IPEs (0.66%; 95% CI, 0.53%-0.83%) identified at initial clinical interpretation.

CONCLUSIONS

Artificial intelligence can efficiently analyze CT examinations to identify potential missed IPE. These results can inform peer-review efforts and quality control and could potentially be implemented in a prospective fashion.

Clinical Outcomes of Incidental Venous Thromboembolism in Cancer and Noncancer Patients: The SWIss Venous ThromboEmbolism Registry (SWIVTER)

OBJECTIVE

 In patients with cancer-associated venous thromboembolism (VTE), the risk of recurrence is similar after incidental and symptomatic events. It is unknown whether the same applies to incidental VTE not associated with cancer.

METHODS AND RESULTS

 We compared baseline characteristics, anticoagulation therapy, all-cause mortality, and VTE recurrence rates at 90 days between patients with incidental (n = 131; 52% without cancer) and symptomatic (n = 1,931) VTE included in the SWIss Venous ThromboEmbolism Registry (SWIVTER). After incidental VTE, 114 (87%) patients received anticoagulation therapy for at least 3 months. The mortality rate was 9.2% after incidental and 8.4% after symptomatic VTE for hazard ratio (HR) 1.10 (95% confidence interval [CI] 0.49-2.50). After adjustment for competing risk of death, recurrence rate was 3.1 versus 2.8%, respectively, for sub-HR 1.07 (95% CI 0.39-2.93). These results were consistent among cancer (mortality: 15.9% vs. 12.6%; HR 1.32, 95% CI 0.67-2.59; recurrence: 4.8% vs. 4.7%; HR 1.02, 95% CI 0.30-3.42) and noncancer patients (mortality: 2.9% vs. 2.1%; HR 1.37, 95% CI 0.33-5.73; recurrence: 1.5% vs. 2.3%; HR 0.63, 95% CI 0.09-4.58). Patients with incidental VTE who received anticoagulation therapy for at least 3 months had lower mortality (4% vs. 41%) and recurrence rate (1% vs. 18%) compared with those who did not.

CONCLUSION

 In SWIVTER, more than half of incidental VTE events occurred in noncancer patients who often received anticoagulation therapy. Among noncancer patients, early mortality and recurrence rates were similar after incidental versus symptomatic VTE. Our findings suggest that anticoagulation therapy for incidental VTE may be beneficial regardless of the presence of cancer.

Special Considerations in Pulmonary Embolism: Clot-in-Transit and Incidental Pulmonary Embolism

This article describes 2 relatively rare, but complex situations in pulmonary embolism (PE): clot-in-transit (CIT), incidental PE (IPE). CIT describes a venous thromboembolism that has become lodged in the right heart. CIT is associated with high mortality and presents unique challenges in management. Incidental PE (IPE) describes PE diagnosed on imaging performed for another indication. The treatment is complex because there is often a disconnect between the PE severity on imaging and lack of severity of the clinical presentation. We summarize the available literature and aid clinicians as they manage patients with PE across the clinical severity spectrum.

Epidemiology and outcomes of clinically unsuspected venous thromboembolism in children: A systematic review

BACKGROUND

Clinically unsuspected venous thromboembolic events (uVTE) detected during routine imaging pose a management challenge due to limited knowledge about their clinical significance. Unsuspected VTE are often referred as "asymptomatic," "incidental," or "clinically silent/occult" VTE.

OBJECTIVE

To understand the epidemiology, management, and outcomes of uVTE in children.

METHODS

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search criteria included controlled vocabulary and keywords for VTE, incidental findings, and children (ages ≤ 21 years).

RESULTS

Among 10 875 articles, 51 studies (8354 children with 758 uVTE) were selected. The studies were heterogeneous, I2 96%; P < .0001. Unsuspected VTE were diagnosed in two settings: first, asymptomatic VTE (aVTE) diagnosed through surveillance imaging for VTE (46 studies; n = 5894; aVTE: 715, pooled frequency: 19%, 95% confidence interval [CI]: 13%-24%); second, incidental VTE (iVTE) diagnosed during imaging performed for indications without primary suspicion for VTE (6 studies; n = 2460; iVTE: 43). The majority (94%) of aVTE were associated with central venous lines (CVL). Non-CVL settings included post-spinal surgery, post-splenectomy, trauma, nephrotic syndrome, and newborns. In general, aVTE were reported to have a benign clinical course, were mostly transient, and resolved without intervention and with few immediate or long-term functional complications. Incidental VTE were primarily detected in children with cancer and ranged from tumor-associated thrombi to pulmonary embolism (PE) with insufficient evidence to draw meaningful conclusions about their management.

CONCLUSION

Clinically uVTE were predominantly diagnosed with CVL and their outcomes were generally favorable implying limited benefit of routine surveillance and thromboprophylaxis. Prospective research is needed to clarify the optimal management of iVTE.

Anticoagulant treatment for subsegmental pulmonary embolism

BACKGROUND

Acute pulmonary embolism (PE) is a common cause of death, accounting for 50,000 to 200,000 deaths annually. It is the third most common cause of mortality among the cardiovascular diseases, after coronary artery disease and stroke. The advent of multi-detector computed tomographic pulmonary angiography (CTPA) has allowed better assessment of PE regarding visualisation of the peripheral pulmonary arteries, increasing its rate of diagnosis. More cases of peripheral PEs, such as isolated subsegmental PE (SSPE) and incidental PE, have thereby been identified. These two conditions are usually found in patients with few or none of the classic PE symptoms such as haemoptysis or pleuritic pain, acute dyspnoea or circulatory collapse. However, in patients with reduced cardiopulmonary reserve, classic PE symptoms can be found with isolated SSPEs. Incidental SSPE is found casually in asymptomatic patients, usually by diagnostic imaging performed for other reasons (for example routine CT for cancer staging in oncology patients). Traditionally, all PEs are anticoagulated in a similar manner independent of their location, or number and size of the thrombi. It has been suggested that many patients with SSPE may be treated without benefit, increasing adverse events by a possible unnecessary use of anticoagulants. Patients with isolated SSPE, or incidental PE, may have a more benign clinical presentation compared to those with proximal PEs. However, the clinical significance in patients, and their prognosis, needs to be studied to evaluate whether anticoagulation therapy is required. This is the second update of the Cochrane systematic review published in 2014.

OBJECTIVES

To assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 November 2019. We also undertook reference checking to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials of anticoagulation therapy versus control in patients with SSPE or incidental SSPE.

DATA COLLECTION AND ANALYSIS

Two review authors inspected all citations identified to ensure reliable assessment. If relevant studies were identified, we planned for two review authors to independently extract data and to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We did not identify any studies that met the inclusion criteria.

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials to assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. Well-conducted research is required before informed practice decisions can be made.

What's new in the prevention and treatment of cancer-associated thrombosis?

Venous thromboembolism (VTE) is a common complication in ambulatory cancer patients receiving chemotherapy. Current clinical guidelines recommend against the use of routine primary thromboprophylaxis in unselected ambulatory cancer patients. The Khorana score is a risk assessment tool derived and prospectively validated for the identification of cancer patients at high risk of thrombotic complications. Recently, 2 randomized, controlled trials have assessed the use of low-dose direct oral Xa inhibitors, apixaban and rivaroxaban, for the prevention of cancer-associated thrombosis in ambulatory patients at intermediate to high risk of VTE (Khorana score ≥2). Taken together, these trials have shown that low-dose direct oral Xa inhibitors reduce the risk of VTE in this patient population without a significant increase in major bleeding. These results should encourage clinicians to consider the use of primary thromboprophylaxis in ambulatory cancer patients at intermediate to high risk of VTE who do not have any apparent risk factors for bleeding. The direct oral Xa inhibitors have also been assessed in the acute management of cancer-associated thrombosis. Current evidence suggests that these drugs are a convenient, effective, and safe option for the management of acute VTE in many cancer patients. Low-molecular weight heparin, however, may continue to be the treatment of choice depending on the presence of bleeding risk factors, the type of cancer, drug-drug interactions, and patient preferences.

Oncologic Emergencies: Too Much Clotting-Venous Thromboembolism in Malignancy

BACKGROUND

Malignancy predisposes patients to higher risk of venous thromboembolism (VTE), which is the second leading cause of death in patients with cancer.

OBJECTIVE

This narrative review evaluates VTE in malignancy and the emergency medicine investigation and management of this patient population.

DISCUSSION

Patients with malignancy are at higher risk of VTE, including deep venous thrombosis (DVT) and pulmonary embolism (PE). Risk factors include the underlying cancer, other hematologic disorders, cancer therapies, and underlying comorbidities. While patients with malignancy and VTE can present similarly to those without malignancy, incidental VTE is more common in cancer patients. Existing scores such as the Wells and Revised Geneva score can assist in risk stratification in patients with malignancy. A negative D-dimer result in the appropriately risk-stratified patient can be used to exclude VTE, though D-dimer is more commonly elevated at baseline in patients with malignancy. Several scoring systems may be useful to predict recurrent risk of VTE, including the Khorana and Ottawa scores. Treatment includes anticoagulation with direct oral anticoagulants (DOACs) or low molecular weight heparin (LMWH). Outpatient therapy may be appropriate in select patients.

CONCLUSIONS

This narrative review provides key updates in the assessment and management of cancer patients with VTE.

Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update

PURPOSE

To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer.

METHODS

PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed.

RESULTS

The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE.

RECOMMENDATIONS

Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.Additional information is available at www.asco.org/supportive-care-guidelines.

Retrospective evaluation of the efficacy and safety of rivaroxaban in patients with cancer-associated venous thromboembolism: A single-center study

ABSTRCT

The purpose of this study was to evaluate the efficacy and safety of rivaroxaban for the treatment of cancer-associated venous thromboembolism (VTE).We performed a retrospective chart review of cancer patients with a pulmonary embolism, deep vein thrombosis, or both. Our analysis included all patients who received rivaroxaban from March 2013 to June 2016 at the Hemato-Oncology Division at the Pusan National University Hospital in Korea.Preliminary results identified 123 patients with a history of cancer that were treated with rivaroxaban. The average duration of rivaroxaban therapy was 95.25 days. While 35 patients had resolved VTE after the initiation of rivaroxaban, only one patient had it recur on rivaroxaban treatment. Major bleeding was observed in 6 (4.9%) patients and minor bleeding in 12 (9.8%) patients. The majority of bleeding events occurred spontaneously and most incidences of bleeding could be treated conservatively. Recurrence and major bleeding events on rivaroxaban were relatively low despite the fact that many patients had metastatic disease. Among 52 patient deaths (42.3%), none were due to VTE or bleeding complications; the cause of death in the majority of cases was cancer progression.Rivaroxaban is effective and safe for the treatment of cancer-associated VTE.

Treatment and Long-Term Clinical Outcomes of Incidental Pulmonary Embolism in Patients With Cancer: An International Prospective Cohort Study

PURPOSE

Pulmonary embolism is incidentally diagnosed in up to 5% of patients with cancer on routine imaging scans. The clinical relevance and optimal therapy for incidental pulmonary embolism, particularly distal clots, is unclear. The aim of the current study was to assess current treatment strategies and the long-term clinical outcomes of incidentally detected pulmonary embolism in patients with cancer.

PATIENTS AND METHODS

We conducted an international, prospective, observational cohort study between October 22, 2012, and December 31, 2017. Unselected adults with active cancer and a recent diagnosis of incidental pulmonary embolism were eligible. Outcomes were recurrent venous thromboembolism, major bleeding, and all-cause mortality during 12 months of follow-up. Outcome events were centrally adjudicated.

RESULTS

A total of 695 patients were included. Mean age was 66 years and 58% of patients were male. Most frequent cancer types were colorectal (21%) and lung cancer (15%). Anticoagulant therapy was initiated in 675 patients (97%), of whom 600 (89%) were treated with low-molecular-weight heparin. Recurrent venous thromboembolism occurred in 41 patients (12-month cumulative incidence, 6.0%; 95% CI, 4.4% to 8.1%), major bleeding in 39 patients (12-month cumulative incidence, 5.7%; 95% CI, 4.1% to 7.7%), and 283 patients died (12-month cumulative incidence, 43%; 95% CI, 39% to 46%). The 12-month incidence of recurrent venous thromboembolism was 6.4% in those with subsegmental pulmonary embolism compared with 6.0% in those with more proximal pulmonary embolism (subdistribution hazard ratio, 1.1; 95% CI, 0.37 to 2.9; P = .93).

CONCLUSION

In patients with cancer with incidental pulmonary embolism, risk of recurrent venous thromboembolism is significant despite anticoagulant treatment. Patients with subsegmental pulmonary embolism seemed to have a risk of recurrent venous thromboembolism comparable to that of patients with more proximal clots.

Overdiagnosis of pulmonary embolism: definition, causes and implications

Overuse of computed tomography pulmonary angiography to diagnose pulmonary embolism in people who have only a low pre-test probability of pulmonary embolism has received significant attention in the past. The issue of overdiagnosis of pulmonary embolism, a potential consequence of overtesting, has been less explored. The term “overdiagnosis”, used in a narrow sense, describes a correct (true positive) diagnosis in a person but without any associated harm. The aim of this review is to summarise literature on the topic of overdiagnosis of pulmonary embolism and translate this epidemiological concept into the clinical practice of respiratory professionals. The review concludes that the location of pulmonary embolism at a subsegmental level, rather than whether a diagnosis was made incidentally or following an investigation for suspected pulmonary embolism, is the best predictor for situations in which anticoagulation may not be necessary. In the absence of strong evidence of the optimal management of subsegmental pulmonary embolism, treatment decisions should be made case by case, taking into account the patient's situation and preference.

A suggested definition of overdiagnosis of pulmonary embolism: a diagnosis of pulmonary embolism that, if left untreated, would not lead to more harm than if it were treated with anticoagulation therapy, independent of symptomshttp://ow.ly/wgAK30nr5IV

Rivaroxaban for Thromboprophylaxis in High-Risk Ambulatory Patients with Cancer

BACKGROUND

Ambulatory patients receiving systemic cancer therapy are at varying risk for venous thromboembolism. However, the benefit of thromboprophylaxis in these patients is uncertain.

METHODS

In this double-blind, randomized trial involving high-risk ambulatory patients with cancer (Khorana score of ≥2, on a scale from 0 to 6, with higher scores indicating a higher risk of venous thromboembolism), we randomly assigned patients without deep-vein thrombosis at screening to receive rivaroxaban (at a dose of 10 mg) or placebo daily for up to 180 days, with screening every 8 weeks. The primary efficacy end point was a composite of objectively confirmed proximal deep-vein thrombosis in a lower limb, pulmonary embolism, symptomatic deep-vein thrombosis in an upper limb or distal deep-vein thrombosis in a lower limb, and death from venous thromboembolism and was assessed up to day 180. In a prespecified supportive analysis involving the same population, the same end point was assessed during the intervention period (first receipt of trial agent to last dose plus 2 days). The primary safety end point was major bleeding.

RESULTS

Of 1080 enrolled patients, 49 (4.5%) had thrombosis at screening and did not undergo randomization. Of the 841 patients who underwent randomization, the primary end point occurred in 25 of 420 patients (6.0%) in the rivaroxaban group and in 37 of 421 (8.8%) in the placebo group (hazard ratio, 0.66; 95% confidence interval [CI], 0.40 to 1.09; P = 0.10) in the period up to day 180. In the prespecified intervention-period analysis, the primary end point occurred in 11 patients (2.6%) in the rivaroxaban group and in 27 (6.4%) in the placebo group (hazard ratio, 0.40; 95% CI, 0.20 to 0.80). Major bleeding occurred in 8 of 405 patients (2.0%) in the rivaroxaban group and in 4 of 404 (1.0%) in the placebo group (hazard ratio, 1.96; 95% CI, 0.59 to 6.49).

CONCLUSIONS

In high-risk ambulatory patients with cancer, treatment with rivaroxaban did not result in a significantly lower incidence of venous thromboembolism or death due to venous thromboembolism in the 180-day trial period. During the intervention period, rivaroxaban led to a substantially lower incidence of such events, with a low incidence of major bleeding. (Funded by Janssen and others; CASSINI ClinicalTrials.gov number, NCT02555878.).

How I treat cancer-associated venous thromboembolism

Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a common complication of cancer and is associated with significant morbidity and mortality. Several cancer-related risk factors contribute to the development of VTE including cancer type and stage, chemotherapy, surgery, and patient-related factors such as advanced age and immobilization. Patients with cancer frequently undergo diagnostic imaging scans for cancer staging and treatment response evaluation, which is increasing the underlying risk of VTE detection. The management of cancer-associated VTE is challenging. Over the years, important advances have been made and, recently, randomized controlled trials have been published helping clinicians' management of this patient population. In this review, we will discuss common cancer-associated VTE scenarios and critically review available evidence to guide treatment decisions.

Apixaban for the prevention of venous thromboembolism in high-risk ambulatory cancer patients receiving chemotherapy: Rational and design of the AVERT trial

Patients with active cancer have a heightened risk of venous thromboembolism (VTE). This risk is further increased by the initiation of chemotherapy. Although previous studies have suggested that the use of parenteral thromboprophylaxis in all ambulatory cancer patients receiving chemotherapy significantly decreases the rate of VTE, current clinical practice guidelines do not recommend routine use of thromboprophylaxis in this patient population. A major criticism of these studies has been the inclusion of patients at lower risk for VTE, which may have diluted the potential beneficial effect of the parenteral thromboprophylaxis. It is therefore imperative to appropriately risk stratify ambulatory cancer patients using a validated scoring system (e.g. Khorana risk score) in order to identify those most likely to benefit from thromboprophylaxis. Direct oral anticoagulants, such as apixaban, may offer a convenient and safe option for thromboprophylaxis. As such, AVERT will randomize 574 ambulatory cancer patients receiving chemotherapy who are at high-risk for VTE (as defined by a Khorana score of ≥2) to Apixaban 2.5 mg BID versus placebo. The primary study outcome will be the first episode of objectively documented symptomatic or incidental VTE (deep vein thrombosis and/or pulmonary embolism) within the first 6 months (180 days ± 3) following initiation of the blinded study drug for both intervention and placebo groups. The secondary safety outcomes include major bleeding, clinically relevant non-major bleeding, and overall survival rates. This study will hopefully offer evidence regarding the benefit of apixaban in ambulatory patients at high risk for VTE receiving chemotherapy.

Venous Thromboembolism and Cancer

PURPOSE OF REVIEW

This review aims to summarize the epidemiology, current pathophysiologic understanding, and state-of-the-art treatment of venous thromboembolism (VTE) in cancer patients.

RECENT FINDINGS

The risk of VTE varies among cancer patients. Recently introduced prediction models better identify those at high risk of VTE. New mechanisms underlying hypercoagulability in cancer have been uncovered. Initial data on the efficacy of direct oral anticoagulants (DOACs) compared with low-molecular weight heparin to treat VTE in patients with cancer are promising. However, they may be associated with higher risk of gastrointestinal bleeding. VTE causes significant morbidity and mortality in cancer patients. Our understanding of the mechanisms of VTE, including those associated with cancer treatments, has significantly grown. The assessment of the benefit/risk balance of VTE treatment remains challenging in many patients with cancer. The introduction of DOACs has expanded treatment options, but knowledge on their efficacy and safety is incomplete.

Advances in managing and preventing thromboembolic disease in cancer patients

PURPOSE OF REVIEW

To update on new data for low-molecular weight heparins (LMWHs) and the direct oral anticoagulants (DOACs) for the treatment and prevention of cancer-associated thrombosis (CAT), to discuss progress with the risk-adaptive management scores (RAMS) and update on increased dose primary thromboprophylaxis (IDPTP).

RECENT FINDINGS

In a pooled meta-analysis of 1132 cancer patients who received DOACs vs. vitamin K analogues (VKAs), recurrence of venous thromboembolism (VTE) was reduced from 6.0% on VKA schedules to 3.9% on DOACs. In a randomized trial of warfarin vs. once daily sc. tinzaparin (175 IU/kg), cumulative 6-month VTE incidence reduced from 10.5 to 7.2% [hazard ratio, 0.65 (95% confidence interval, 0.41-1.03); P = 0.07]. Despite early suggestions that DOACs may have a role in CAT, 3-6 months of LMWH remain the standard for initial treatment of CAT. A prospective comparison of RAMS found the Vienna CATS or the PROTECHT scores superior to the Khorana score but concluded that RAMS did not perform well enough to be used in the clinic. An efficacy scale of LMWHs in pancreatic cancer facilitates IDPTP. Practical implementation of IDPTP was needed to control the 40% VTE incidence of the HALO-109-202 study in metastatic pancreatic cancer.

SUMMARY

DOACs have some encouraging data, but LMWHs remain the standard for CAT treatment. RAMS generated to predict VTE occurrence or recurrence are still of unproven significance and IDPTP for advanced pancreatic cancer has tools and guidance for implementation.

Cancer prognosis in patients with venous thromboembolism (VTE) and patients with clinical and laboratory biomarkers predictive of VTE risk

Venous thromboembolism (VTE) is a well-documented complication of cancer and its treatment. While VTE contributes significant morbidity and some thrombotic mortality to cancer patients, a growing body of clinical and experimental data supports the finding that VTE is an important prognostic marker for cancer progression and mortality. This would suggest that hemostatic activation is an expression of an aggressive tumor phenotype. A number of clinical and laboratory biomarkers have been shown to be predictive of an increased risk of cancer-associated VTE. In addition, it is now becoming apparent that these same biomarkers are also predictive of cancer mortality. The application of this information to reduce cancer-associated VTE and improve cancer survival await the results of ongoing prophylaxis antithrombotic studies.

Incidental pulmonary embolism in oncology patients with current macroscopic malignancy: incidence in different tumour type and impact of delayed treatment on survival outcome

OBJECTIVES

To evaluate the incidence and outcome of incidental pulmonary embolism (iPE) in patients with current macroscopic malignancy and delayed anticoagulation due to late reporting of CT scan.

METHODS

Reports of CT thorax with i.v. contrast done on oncology patients between 1 January 2015 and 31 December 2015 in two district general hospitals in UK were reviewed. Electronic patient records of iPE patients were reviewed for demographic and treatment information.

RESULTS

26 iPEs were reported in 1,604 scans (731 patients), incidence 1.6%; female = 15; median age = 66 (range 32-90); main artery = 10; lobar artery = 8; segmental = 7; subsegmental = 1; median time (range) from scan to reporting = 1 day (0-60); scan to anticoagulation = 5 days (0-61) (three had no treatment); scan to death = 7 months (1-22+) with nine still alive and two lost to follow up. All had metastatic disease. There was no sudden death. None of the patients whose anticoagulation started more than 5 days after the iPE CT scan died within 3 months. iPE was absent in all repeat staging CT scans (done average 3.4 months after the anticoagulation) in 16 patients, without any anticoagulation in one patient with segmental iPE.

CONCLUSION

Incidence of iPE in patients with current macroscopic malignancy is low-1.6%-mostly seen in lung, breast and colorectal cancer probably due to frequency of imaging. A few days' delay in anticoagulation does not appear to have an impact on the risk of sudden cardiac death. Advances in knowledge: This study tells us that iPE is infrequent, that it can be treated appropriately with anticoagulation, but this does not necessarily need to begin on the same day of diagnosis.

Highlights from the Tenth International Symposium of Thrombosis and Anticoagulation (ISTA X), September 22 and 23, 2017, Salvador, Bahia, Brazil

To discuss and share knowledge about advances in the care of patients with thrombotic disorders, the Tenth International Symposium of Thrombosis and Anticoagulation was held in Salvador, Bahia, Brazil, on September 22 and 23, 2017. This scientific program was developed by clinicians for clinicians and was promoted by two major clinical research institutes-the Brazilian Clinical Research Institute and the Duke Clinical Research Institute of the Duke University School of Medicine. Comprising academic presentations and open discussion, the symposium had as its primary goal to educate, motivate, and inspire internists, cardiologists, hematologists, and other physicians by convening national and international visionaries, thought-leaders, and dedicated clinician-scientists. This paper summarizes the symposium proceedings.

Prognostic assessment for patients with cancer and incidental pulmonary embolism

Background

An incidental/unsuspected diagnosis of pulmonary embolism (IPE) in cancer patients is a frequent occurrence. This single-institution analysis of uniformly managed patients investigates short and long-term outcomes and proposes a prognostic risk score, aiming to assist clinical decision-making.

Methods

Data from a prospectively recorded cohort of 234 consecutive cancer patients with IPE were analysed. Multivariate logistic regression and the Cox regression survival methods were used to identify factors with independent association with early (30-day, 3-month, 6-month) mortality and survival. Receiver operator characteristic analysis (ROC) was used to assess appropriate cut-offs for continuous variables and the fitness of prognostic scoring.

Results

30-day, 3-month and 6-month mortality was 3.4% (n = 8), 15% (n = 35) and 31% (n = 72) respectively. Recurrence during anticoagulation occurred in 2.6% (n = 6) and major haemorrhage in 2.1% (n = 5) of the patients. A prognostic score incorporating performance status (0 vs 1–2 vs 3–4) and the presence of new or worsening symptoms, with and without the consideration of the presence of incurable malignancy, correlated with overall survival (p < .001 respectively) as well as early mortality (AUC = .821, p = .004 and AUC = .805, p = 0.006, respectively).

Conclusion

A simple prognostic score incorporating basic oncologic clinical assessment and self-reported symptomatology could reliably stratify the mortality risk of ambulant cancer patients and IPE.

Trial registration

Audit registration No. 2013.287, Hull and East Yorkshire Hospitals Trust, 29/11/2013.

Electronic supplementary material

The online version of this article (10.1186/s12959-017-0157-x) contains supplementary material, which is available to authorized users.

Incidental venous thromboembolism: is anticoagulation indicated?

Patients with cancer have a high risk of venous thromboembolism (VTE) and about one-half of these events are incidentally detected. The prognosis of incidental VTE appears to be similar to symptomatic events, with comparably high rates of recurrent VTE in this patient population. In the absence of major contraindications, anticoagulant treatment with low-molecular-weight heparin for 3 to 6 months is generally recommended for incidental proximal deep vein thrombosis as well as for incidental pulmonary embolism that involves multiple subsegmental or more proximal pulmonary arteries. The decision of whether to extend treatment beyond 3 to 6 months should be evaluated on a case-by-case basis after periodic reassessment of the risks factors for bleeding and recurrent VTE while also taking into account patient preferences. The clinical relevance of a single incidental subsegmental pulmonary embolism without concomitant deep vein thrombosis is uncertain and either a watchful approach or a shorter course of anticoagulation to minimize the bleeding risk may also be considered. Preliminary evidence suggests that anticoagulation treatment may be beneficial for cancer patients with incidental distal deep vein thrombosis or incidental splanchnic vein thrombosis.

Edoxaban for treatment of venous thromboembolism in patients with cancer

Direct oral anticoagulants may be effective and safe for treatment of venous thromboembolism (VTE) in cancer patients, but they have not been compared with low-molecular-weight heparin (LMWH), the current recommended treatment for these patients. The Hokusai VTE-cancer study is a randomised, open-label, clinical trial to evaluate whether edoxaban, an oral factor Xa inhibitor, is non-inferior to LMWH for treatment of VTE in patients with cancer. We present the rationale and some design features of the study. One such feature is the composite primary outcome of recurrent VTE and major bleeding during a 12-month study period. These two complications occur frequently in cancer patients receiving anticoagulant treatment and have a significant impact. The evaluation beyond six months will fill the current gap in the evidence base for the long-term treatment of these patients. Based on the observation that the risk of recurrent VTE in patients with active cancer is similar to that in those with a history of cancer, the Hokusai VTE-cancer study will enrol patients if whose cancer was diagnosed within the past two years. In addition, patients with incidental VTE are eligible because their risk of recurrent VTE is similar to that in patients with symptomatic disease. The unique design features of the Hokusai VTE-cancer study should lead to enrolment of a broad spectrum of cancer patients with VTE who could benefit from oral anticoagulant treatment.

Lung Cancer Complicated With Asymptomatic Pulmonary Embolism: Clinical Analysis of 84 Patients

Background and Objective:

Pulmonary embolism is potentially life-threatening in patients with lung cancer, but the clinical studies on patients with lung cancer having asymptomatic pulmonary embolism were barely reported.

Methods:

Clinical data of patients with lung cancer were obtained from the Department of Respiratory and Critical Care Medicine of Tianjin Chest Hospital during July 2012 and June 2015 and were reviewed retrospectively. A total of 28 patients with lung cancer having pulmonary embolism (LP group) were enrolled, and another 56 cases with lung cancer alone (LC group) were enrolled as controls.

Results:

Seventeen (60.7%) of 28 patients in the LP group developed adenocarcinoma, which was more frequent than that in the LC group (P < .01); the LP group displayed lower counts of hemoglobin and albumin than the LC group (P < .05); the counts of leukocyte (white blood cell) and d-dimer of patients in the LP group were also higher than those in the LC group (P < .05). The high-incidence period of pulmonary embolism among 17 asymptomatic cases in the LP group was 3.6 months postdiagnosis (95% confidence interval, 3.2-4.0), showing a significant difference with that of other 11 patients with symptomatic pulmonary embolism, which was 10.5 months (95% confidence interval, 8.88-12.12; P < .01). Survival analysis displayed that median survival time of patients with asymptomatic pulmonary embolism was 7.2 months (95% confidence interval, 5.86-8.56), while that of symptomatic pulmonary embolism was 2.8 months (95% confidence interval, 2.48-3.12). Log-rank examination showed that survival time of asymptomatic pulmonary embolism group was statistically longer than that of symptomatic pulmonary embolism group.

Conclusion:

Lung adenocarcinoma, chemotherapy, hyperleukocytosis, and d-dimer increment were the risk factors for lung cancer combined with asymptomatic pulmonary embolism.

Incidence and Effect of Thromboembolic Events in Radical Cystectomy Patients Undergoing Preoperative Chemotherapy for Muscle-invasive Bladder Cancer

BACKGROUND

We evaluated the incidence and effect of thromboembolic events (TEEs) in patients with muscle-invasive bladder cancer treated with preoperative chemotherapy (POC) and radical cystectomy (RC) with pelvic lymph node dissection (PLND).

PATIENTS AND METHODS

We performed a retrospective review of all patients who had undergone POC followed by RC plus PLND for muscle-invasive bladder cancer from June 2000 to January 2013 (n = 357). The chemotherapy type (neoadjuvant vs. induction), incidence and timing of TEE diagnosis (preoperatively vs. ≤ 90 days postoperatively), and effect of TEEs on clinical outcomes were recorded.

RESULTS

Overall, 79 patients (22%; 95% confidence interval [CI], 18%-27%) experienced a TEE: 57 (16%) occurred during POC and 22 (6.2%) were diagnosed postoperatively. Forty patients (11%; 95% CI, 8.1%-15%) required an inferior vena cava filter. We found no significant differences in neoadjuvant versus induction chemotherapy and the risk of TEEs (difference, 3.3%; 95% CI, -5% to 12%; P = .5). No significant difference were found in the rates of POC completion according to the presence of a TEE (difference, 1.0%; 95% CI, -11% to 13%; P = .9). The occurrence of TEE did not significantly affect other perioperative outcomes. The risk of recurrence and overall survival were not associated with TEE on multivariable analysis.

CONCLUSION

We found a high incidence of TEEs (22%) in patients undergoing POC before RC plus PLND, with a 16% incidence in the preoperative period. TEEs in the POC setting leads to invasive procedures; however, we did not find a significant effect on POC completion or postoperative complication risk. Further research is required to determine whether preventative TEE measures during POC can improve clinical outcomes.

Management of incidental pulmonary embolism

Incidental pulmonary embolism (PE) is a frequent finding on routine computed tomography (CT) scans of the chest, occurring in 1.1% of coronary CT scans and 3.6% of oncological CT scans. Despite this high frequency, optimal management of incidental PE has not been addressed in clinical trials and remains the subject of debate. Although these CT scans have not been performed with a dedicated PE protocol and have suboptimal contrast enhancement, diagnosis of incidental PE has been shown to be accurate up to the segmental and subsegmental arteries. The embolic load in incidental PE is lower than that in symptomatic PE. Even so, observational studies suggest that the natural course of incidental PE is similar to that of symptomatic PE with regard to the risk of recurrent venous thrombotic disease and mortality. Interestingly, the increased use of more advanced CT technology has coincided with an increase in the rate of incidental subsegmental PE, as is the case for symptomatic subsegmental PE. Although clinical trials are lacking, and observational data are limited to cancer-associated incidental PE, the consensus is that the management of incidental PE is identical to that of symptomatic PE, including the choice of optimal drug class, outpatient treatment and total duration of treatment.

High prevalence of incidental and symptomatic venous thromboembolic events in patients with advanced pancreatic cancer under palliative chemotherapy: A retrospective cohort study

OBJECTIVES

Pancreatic cancer patients are at high risk for venous thromboembolic events (VTEs), and chemotherapy is a known additional risk factor. In this context, there is a controversial discussion whether prophylactic anticoagulation should be offered to all outpatients receiving chemotherapy.

METHODS

In this retrospective study, we analyzed incidental and symptomatic VTEs in 150 pancreatic cancer patients receiving either gemcitabine-based chemotherapy or chemotherapy according to the FOLFIRINOX protocol.

RESULTS

VTEs were identified in 25% of patients, but were not associated with an adverse survival. There was no significant difference in VTE incidence between patients treated with gemcitabine-based chemotherapy or the more intensive FOLFIRINOX protocol. A commonly used risk score to predict VTEs in cancer patients did not predict the occurrence of VTEs in our patients. The occurrence of VTEs was not associated with one of the recently described pancreatic cancer subtypes.

CONCLUSION

One quarter of pancreatic cancer patients treated with palliative chemotherapy develops symptomatic or incidental VTEs that cannot be predicted by type of chemotherapy, subtype of pancreatic cancer or a commonly used risk score. Further studies are necessary to identify patients at risk, and to better define which patients at risk should be treated with prophylactic anticoagulation.

Cancer and Venous Thromboembolic Disease: A Review

Venous thromboembolism (VTE), including deep-vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in cancer patients. Patients with cancer are six times more likely to develop VTE than their noncancer counterparts, and VTE is the second leading cause of death in cancer patients. Despite the publication of major consensus guidelines setting out recommendations for thromboprophylaxis in cancer patients, there remains a gulf between these guidelines and clinical practice. In general, thromboprophylaxis is recommended for most patients hospitalized with active cancer. Furthermore, outpatient thromboprophylaxis may be used in carefully selected high-risk ambulatory patients. Certain areas of controversy still remain. Although low-molecular-weight heparin has been shown to be superior to vitamin K antagonists in cancer patients, the role of direct oral anticoagulants is still uncertain. Moreover, recurrent thromboembolism, bleeding, and thrombocytopenia are frequently seen in cancer patients. Optimal anticoagulation in such instances presents a major challenge to clinicians. Modern computed tomography techniques have resulted in an increase in the detection of "incidental" VTE. Despite a growing body of evidence promulgating standard anticoagulant treatment in such cases, these cases present further challenges for members of the multidisciplinary team. The Oncologist 2017;22:199-207Implications for Practice: This article discusses venous thromboembolism (VTE) in patients with malignancy. Practical guidance is offered on how to prevent, diagnose, and treat VTE in cancer patients. The management of "challenging" cases of VTE is also discussed.

Clinical features and short-term outcomes of cancer patients with suspected and unsuspected pulmonary embolism: the EPIPHANY study

The study aimed to identify predictors of overall 30-day mortality in cancer patients with pulmonary embolism including suspected pulmonary embolism (SPE) and unsuspected pulmonary embolism (UPE) events. Secondary outcomes included 30- and 90-day major bleeding and venous thromboembolism (VTE) recurrence.

The study cohort included 1033 consecutive patients with pulmonary embolism from the multicentre observational ambispective EPIPHANY study (March 2006–October 2014). A subgroup of 497 patients prospectively assessed for the study were subclassified into three work-up scenarios (SPE, truly asymptomatic UPE and UPE with symptoms) to assess outcomes.

The overall 30-day mortality rate was 14%. The following variables were associated with the overall 30-day mortality on multivariate analysis: VTE history, upper gastrointestinal cancers, metastatic disease, cancer progression, performance status, arterial hypotension <100 mmHg, heart rate >110 beats·min−1, basal oxygen saturation <90% and SPE (versus overall UPE).

The overall 30-day mortality was significantly lower in patients with truly asymptomatic UPE events (3%) compared with those with UPE-S (20%) and SPE (21%) (p<0.0001). Thirty- and 90-day VTE recurrence and major bleeding rates were similar in all the groups.

In conclusion, variables associated with the severity of cancer and pulmonary embolism were associated with short-term mortality. Our findings may help to develop pulmonary embolism risk-assessment models in this setting.

Signs and Symptoms of Venous Thromboembolism and Survival Outcome of Endometrial Cancer

Objective

This study aimed to evaluate if the presence of venous thromboembolism (VTE) diagnosed with subjective and objective measurements correlates with the survival outcome in patients with endometrial cancer.

Methods

A retrospective study was conducted on patients with endometrial cancer who developed VTE between cancer diagnosis and follow-up from 1999 to 2013. Disease-specific survival after VTE diagnosis was evaluated according to VTE symptoms and vital signs.

Results

Among 827 endometrial cancer cases during the study period, there were 72 (8.7%) patients with VTE identified (pulmonary embolism [PE] with or without deep vein thrombosis [DVT], n = 34; and DVT alone n = 38). In the PE group, decreased disease-specific survival after the diagnosis of VTE was associated with fatigue, systolic blood pressure (BP) less than 120 mm Hg, diastolic BP less than 70 mm Hg, and a heart rate 90 beats per minute or greater (all,P< 0.05) in a univariate analysis. Symptomatic PE was associated with decreased survival as compared to asymptomatic PE (2-year rate; 23.1% vs 77.8%,P< 0.01). In a multivariate analysis controlling for symptoms of VTE, signs, and tumor factors, a diastolic BP less than 70 mm Hg (adjusted-hazard ratio [HR], 10.0; 95% confidence interval, 2.70–37.1;P< 0.01) and HR greater than 90 beats per minute (adjusted-HR, 8.06; 95% confidence interval, 2.36–27.5;P< 0.01) remained as independent prognostic factors for decreased disease-specific survival after PE diagnosis. Patients with PE presenting with low diastolic BP and high heart rate resulted in a dismal survival outcome (diastolic BP < 70 mm Hg/heart rate ≥ 90 beats per minute vs diastolic BP ≥ 70 mm Hg/heart rate < 90 beats per minute; 0% vs 85.7%,P< 0.01). In the group of patients with DVT alone, no signs or symptoms correlated with survival outcome (all,P> 0.05).

Conclusions

Our results suggested that both signs and symptoms of PE are important consideration in the management of patients with endometrial cancer with PE.

Venous thromboembolism in cancer patients: risk assessment, prevention and management

Thrombosis and thromboembolic events contribute to significant morbidity in cancer patients. Venous thrombosis embolism (which includes deep vein thrombosis and pulmonary embolism) accounts for a large percentage of thromboembolic events. Appropriate identification of cancer patients at high risk for venous thromboembolism and management of thromboembolic event is crucial in improving the quality of care for cancer patients. However, thromboembolism in cancer patients is a complex problem and the management has to be tailored to each individual. The focus of this review is to understand the complex pathology, physiology and risk factors that drive the process of venous thrombosis and embolism in cancer patients and the current guidelines in management.