Venous thromboembolism as first manifestation of cancer

Selective but not pan-CDK inhibition abrogates 5-FU-driven tissue factor upregulation in colon cancer

Thromboembolic events are complications in cancer patients and hypercoagulability has been linked to the tissue factor (TF) pathway, making this an attractive target. Here, we investigated the effects of chemotherapeutics and CDK inhibitors (CDKI) abemaciclib/palbociclib (CDK4/6), THZ-1 (CDK7/12/13), and dinaciclib (CDK1/2/5/9) alone and in combination regimens on TF abundance and coagulation. The human colorectal cancer (CRC) cell line HROC173 was treated with 5-FU or gemcitabine to stimulate TF expression. TF+ cells were sorted, recultured, and re-analyzed. The effect of treatment alone or in combination was assessed by functional assays. Low-dose chemotherapy induced a hypercoagulable state and significantly upregulated TF, even after reculture without treatment. Cells exhibited characteristics of epithelial-mesenchymal transition, including high expression of vimentin and mucin. Dinaciclib and THZ-1 also upregulated TF, while abemaciclib and palbociclib downregulated it. Similar results were observed in coagulation assays. The same anticoagulant activity of abemaciclib was seen after incubation with peripheral immune cells from healthy donors and CRC patients. Abemaciclib reversed 5-FU-induced TF upregulation and prolonged clotting times in second-line treatment. Effects were independent of cytotoxicity, senescence, and p27kip1 induction. TF-antibody blocking experiments confirmed the importance of TF in plasma coagulation, with Factor XII playing a minor role. Short-term abemaciclib counteracts 5-FU-induced hypercoagulation and eventually even prevents thromboembolic events.

Internal Jugular Vein Thrombosis as First Sign of Metastatic Lung Cancer

We describe a case of spontaneous internal jugular vein thrombosis occurring as the first sign of occult lung cancer. The peculiarity of the case was the unusual site of thrombosis and the lack of risk factors for DVT (only a moderated reduction of protein S without inherited thrombophilia) as well as the absence of clinical signs of cancer. This report shows once again the strong association between idiopathic venous thromboembolism and cancer. Hypercoagulation tests confirmed the association between cancer and thrombophilia. Reduction of protein S has been discovered recently in patients with lung cancer but further data are required to confirm this finding. Combined treatment (chemotherapy and radiotherapy) associated with oral anticoagulation therapy was started in our patient at the moment of diagnosis.

Myocardial infarction, ischaemic stroke and pulmonary embolism before and after breast cancer hospitalisation

We studied the occurrence of myocardial infarction (MI), ischaemic stroke (IS) and pulmonary embolism (PE) before and after breast cancer hospitalisation compared with cancer-free controls. For this, women with a first breast cancer hospitalisation during 2000–2007 were selected from the PHARMO Record Linkage System, including drug use and hospitalisations of three million inhabitants in the Netherlands, and matched 1:10 by age to cancer-free women. The occurrence of MI, IS and PE were assessed in the 12 months before and after breast cancer hospitalisation. The study included 11,473 breast cancer patients, with a mean (± SD) age of 59 (± 14) years. Breast cancer patients were two to three times as likely as their cancer-free controls to have had a hospitalisation for PE, MI or IS in the 12 months before diagnosis, though prevalence was <1% in all groups. Breast cancer patients experienced an extreme high risk of PE in the first six months after diag- nosis (hazard ratio [HR] 23.5, 95% confidence interval [CI] 11.1–49.7 compared to controls), which declined gradually to a four times increased risk (HR 3.6, 95%CI 2.4–5.5) more than 12 months after breast cancer hospitalisation. However, incidence was low: less than five events per 1,000 person years during all time periods. For MI and IS we did not observe significant increased HRs after breast cancer hospitalisation compared to controls. Breast cancer patients seem to have a higher risk profile to develop MI and IS, and receive treatment that increases the risk of PE compared to cancer-free controls, although the frequency of hospitalisations was low.

Venous thromboembolism in cancer patients: an underestimated major health problem

Venous thromboembolism (VTE) is a major health problem among patients with cancer, its incidence in this particular population is widely increasing. Although VTE is associated with high rates of mortality and morbidity in cancer patients, its severity is still underestimated by many oncologists. Thromboprophylaxis of VTE now considered as a standard of care is still not prescribed in many institutions; the appropriate treatment of an established VTE is not yet well known by many physicians and nurses in the cancer field. Patients are also not well informed about VTE and its consequences. Many studies and meta-analyses have addressed this question so have many guidelines that dedicated a whole chapter to clarify and expose different treatment strategies adapted to this particular population. There is a general belief that the prevention and treatment of VTE cannot be optimized without a complete awareness by oncologists and patients. The aim of this article is to make VTE a more clear and understood subject.

Hematologic malignancies and thrombosis

Patients with hematologic malignancies have an increased risk of venous thromboembolism (VTE), particularly at diagnosis and during the treatment with chemotherapy, asparaginase or immunomodulatory drugs (IMiDs). A disease-dependent hypercoagulable condition associated with other risk factors like drugs, central venous catheter (CVC), immobility and infections are responsible for this high VTE rate. Thrombotic complications have a significant impact on morbidity and in some cases also on mortality of patients with onco-hematologic diseases, therefore thromboprophylaxis to prevent VTE in this setting is needed. However, thrombocytopenia and hemorrhagic complications pone many difficulties in the management of an anticoagulant or antiaggregant treatment in these patients. Recommendations from current guidelines are limited to multiple myeloma patients treated with thalidomide or lenalidomide associated with dexamethasone or chemotherapy, but hematological clinical departments should implement a policy for prevention and treatment of thromboembolic complications in hematologic malignancies.

Comparative assessment of low-molecular-weight heparins in cancer from the perspective of patient outcomes and survival

Patients with cancer are at high risk of developing venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism. Compared to non-cancer patients, VTE in cancer is more frequently associated with clinical consequences, including recurrent VTE, bleeding, and an increase in the risk of death. Low-molecular-weight heparins (LMWHs) are commonly recommended for the prevention and treatment of VTE in cancer patients because of their favorable risk-to-benefit profile. Indeed, compared with vitamin K antagonists, LMWHs are characterized by a reduced need for coagulation monitoring, few major bleeding episodes, and once-daily dosing, which make these drugs more suitable in the cancer setting. Guidelines have been published recently with the aim to improve the clinical outcomes in cancer patients at risk of VTE and its complications. Coagulation activation in cancer may have a role not only in thrombosis but also in tumor growth and dissemination. Hence, inhibition of fibrin formation has been considered a possible tool against the progression of malignant disease. Clinical studies show that anticoagulant drugs may have a beneficial effect on survival in cancer patients, with a major role for LMWHs. Recently a number of prospective randomized clinical trials to test LMWHs to improve cancer survival as a primary endpoint in cancer patients have been conducted. Although the results are controversial, the interest in this research area remains high.

Clinical outcome in patients with venous thromboembolism and hidden cancer: findings from the RIETE Registry

INTRODUCTION

Although extensive screening in patients with venous thromboembolism (VTE) may result in early identification of hidden cancer, it is unknown whether the prognosis of these patients may be favorably influenced.

PATIENTS AND METHODS

RIETE is an ongoing, prospective registry of consecutive patients with objectively confirmed, symptomatic, acute VTE. We compared the 3-month outcome of patients with hidden cancer with that in patients in whom no symptoms of cancer were noted.

RESULTS

Of 17,475 patients with acute VTE, 2852 (16%) had cancer diagnosed before VTE or during admission. Hidden cancer was detected in 178 (1.2%) of the remaining 14,623 patients. The most common sites were lung, prostate, colorectum, or hematologic, and 51% had metastases. As compared with patients in whom no symptoms of cancer were noted, those with hidden cancer had an increased incidence of recurrent VTE (11.4% vs. 2.1%; P < 0.001), major bleeding (5.1% vs. 2.1%; P = 0.007), and mortality (20% vs. 5.4%; P < 0.001). In the multivariate analysis, patients aged 60-75 years [odds ratio 1.8; 95% CI 1.2-2.7], with idiopathic VTE (odds ratio 3.0; 95% CI 2.2-4.2), with bilateral thrombosis (odds ratio 2.3; 95% CI 1.3-4.1) or with anemia (odds ratio 1.9; 95% CI 1.4-2.6) were at an increased risk for hidden cancer.

CONCLUSIONS

VTE patients with hidden cancer have an increased incidence of recurrences, major bleeding or death during the first 3 months of therapy. With four simple, easily obtainable variables, it is possible to identify a subgroup of VTE patients with a higher risk for hidden cancer.

An unusual presentation of metastatic gastric adenocarcinoma--acute onset of right neck swelling

Central venous thrombosis is an uncommon problem associated with malignancy. We present here a 53-year-old male who visited the emergency room because of right neck swelling. Fluid accumulation over deep neck space led to the diagnosis of suspected hemorrhage, and central venous thrombosis was found by computed tomography. This patient had no other precipitating cause. Autoimmune disorders, hypercoagulation and malignancy surveys were performed during hospitalization. Elevated serum tissue polypeptide antigen and CA130 were noted, and multiple liver metastases were found by another computed tomography. Subsequently, gastric adenocarcinoma was confirmed after gastroendoscopy. Gastric adenocarcinoma with distal metastases was finally diagnosed. This case reminds us that central venous thrombosis is a sign of many diseases. Malignancy, including gastric adenocarcinoma, is one of the causes that should be considered.

Thromboembolic Disorders in Cancer

Complex factors, including substances in cancer cells, cancer treatment effects, and venous stasis associated with chronic illness, blood vessel wall injury, and immobility, interact to place patients with cancer at risk for thrombosis. This article describes the etiology, clinical manifestations, diagnostic tests, and treatments for venous and pulmonary emboli associated with cancer. It explores the nurse's role in assessing patients who are at risk, managing symptomatic thrombosis and primary and secondary prevention of emboli, and administering anticoagulant therapy. As growing numbers of patients are treated in outpatient settings, oncology nurses play a critical role in the coordination of care for patients at risk for thrombosis. A nursing care plan summarizes key nursing strategies for assessment and intervention.

Venous thromboembolism syndrome in gynecological cancer

Venous thromboembolism (VTE) could be presented as an initial clinical feature in some cancer patients or a complication followed by various cancer treatments, which all indicates a poor outcome. This review focuses on elucidating the relationship of VTE and the main gynecological cancers including ovarian, endometrial, and cervical cancers. First, the general VTE information about gynecological cancer are introduced; second, the risk factors of VTE developing in gynecological cancer were discussed; third, we do a retrospective analysis on a novel treatment targeting coagulation cascade; and last, we analyze VTE as a remarkable complication followed by recombinant human erythropoietin and anti-vascular endothelial growth factor treatment in gynecological cancer patients. In summary, the interaction between the coagulation system and cancer progression is a novel promising area to be explored in the study of VTE in patients with gynecological cancer.

Enzymes that hydrolyze adenine nucleotides in platelets from breast cancer patients

The activities of NTPDase (EC 3.6.1.5, apyrase, CD39) and 5'-nucleotidase (EC 3.1.3.5, CD73) enzymes were analyzed in platelets from breast cancer patients. Initially, patients were compared in terms of length (years) of tamoxifen use. The following groups were studied: breast cancer patients who did not use tamoxifen, patients using tamoxifen for 1-48 months, patients using tamoxifen for 49-84 months, and controls (healthy subjects). Results demonstrated that adenosine triphosphate (ATP) hydrolysis was enhanced (F(3,114)=8.53; P<0.001) and adenosine diphosphate (ADP) hydrolysis was reduced (F(3,106)=5.09, P=0.002) as a function of tamoxifen use, while adenosine monophosphate (AMP) hydrolysis was unchanged. Next, patients were compared statistically according to disease stage, determined by the tumor-node-metastasis (TNM) staging system for classifying breast tumor. ATP hydrolysis was significantly elevated in patients with stage I and II breast cancer (F(4,113)=4.35; P=0.003), but was normal in patients with stage III and IV cancer. ADP hydrolysis was reduced in stages II to IV (F(4,105)=3.88, P=0.006) and AMP hydrolysis was elevated in stage II (F(4,105)=3.45 P=0.01), but was normal in stages III and IV. Platelet aggregation time was similar in all patients regardless of tamoxifen use or disease stage. Prothrombin time (PT) and activated partial thromboplastin time (APTT) were also within the normal range and similar among all groups. Similarly, fibrinogen and fibrin degradation product (FDP) were unchanged in all groups. In conclusion, our study demonstrated for the first time that hydrolysis of adenine nucleotides is modified in platelets from breast cancer patients taking tamoxifen.

Characterization of the cell-surface procoagulant activity of T-lymphoblastoid cell lines

The procoagulant activity (PCA) of four T-lymphoblastoid cell lines (CEM-CCRF, Jurkat, Molt-4 and A3.01) at different stages of differentiation has been characterized and compared with that of a monocytoid cell line (THP-1). Four assay systems were employed; the activated partial thromboplastin time (APTT); prothrombin time/tissue factor (TF) activity; a purified factor (F)Xa generation system and cancer procoagulant. High levels of TF activity were seen only with the monocytic cells. However the more differentiated of the T-lymphoblastoid cells (Molt-4 and A3.01) were more active than monocytic cells in supporting FXa generation. This pattern was not repeated for the APTT assay, which was related to cell-surface TF activity, since it was partially inhibited by antiTF antibody. Annexin V totally inhibited the activity observed in all three assay systems, indicating that the PCA of T-lymphoblastoid cells is primarily due to expression of negatively charged phospholipids. However, antiphosphatidylserine antibody even at a high concentration gave only partial inhibition of the activity observed in the APTT and FXa generation systems for the cells compared with almost total inhibition for the phospholipid standard, suggesting either that cellular phosphatidylserine (PS) is less accessible to the antibody, or that PS is not the sole negatively charged phospholipid responsible for this activity. Flow cytometry studies using propidium iodide and annexin V showed that the PCA, although linked to PS exposure, was not the result of apoptosis.

Cancer and thromboembolic disease: how important is the risk of thrombosis?

The overall incidence of postoperative DVT in patients with cancer is twice as high as in cancer-free patients. Immobilisation and chemotherapy increase the risk of thrombosis as does the insertion of central venous lines. Patients with cancer who have established thrombosis exhibit a remarkably high risk of recurrent thromboembolism, particularly in the first months after the interruption of anticoagulant treatment: the risk is double that of non-cancer patients. Even during anticoagulant treatment, the cumulative incidence of recurrent thromboembolism is 3.5 times higher in patients with malignancy than in cancer-free patients. Conversely, there is a high rate of cancer detection in patients with idiopathic VTE: the risk of concomitant cancer is approximately four times higher in these patients than in those with thrombosis triggered by known factors. Extensive screening for cancer in patients with idiopathic venous thrombosis allows early detection of malignancies and identification of malignancy at an early stage.

Venous thromboembolism guidebook

This venous thromboembolism guidebook incorporates evolving contemporary concepts in diagnosis and management of pulmonary embolism (PE) and deep venous thrombosis (DVT) into a user-friendly menu. The purpose of this document is to provide a literature-based review of the current clinical approach to venous thromboembolism and up-to-date references for further study in this important topic.

Pathogenetic mechanisms of thrombosis in malignancy

The interactions between components of the hemostatic system and cancer cells are multifaceted. Strong clinical evidence is accumulating on the prothrombotic tendency of cancer patients, which is enhanced by anticancer therapy, such as surgery and chemotherapy. The mechanisms of thrombus promotion in malignancy include some general responses of the host to the tumor (acute phase, inflammation, angiogenesis) and specific interactions of tumor cells with the clotting/fibrinolysis systems and with blood (leukocytes, platelets) or vascular cells. It is at present difficult to rank the relative weight of these multiple interactions on the basis of the well-recognized clinical evidence of enhanced thrombotic episodes in tumor patients. In any case, the mechanisms explored so far offer a sound experimental basis for prevention/treatment of thrombosis in tumor patients and leave open the possibility that some antithrombotic strategies may also affect the processes of tumor growth and dissemination.