Cancer Therapy-Associated Thrombosis

Postmarketing safety evaluation of pemetrexed using FAERS and JADER databases

Pemetrexed, a multi-target antifolate chemotherapeutic widely used in non-small cell lung cancer (NSCLC) and malignant pleural mesothelioma (MPM), is associated with various adverse drug events (ADEs), some of which may be underrecognized in clinical trials. This study conducted a comprehensive pharmacovigilance analysis using two major spontaneous reporting systems-FAERS (2004Q1-2024Q3) and JADER (2007Q1-2024Q3)-to evaluate pemetrexed-related ADEs. Disproportionality analysis was performed using four algorithms: Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-Item Gamma Poisson Shrinker (MGPS). Time-to-onset (TTO) patterns were assessed using Weibull distribution modeling. A total of 12,026 and 4,522 pemetrexed-related ADE reports were retrieved from FAERS and JADER, respectively. The most frequently reported ADEs included hematologic toxicities (anemia, neutropenia, thrombocytopenia), gastrointestinal disorders (nausea, vomiting, diarrhea), and renal impairment. Strong safety signals were consistently identified for these events. Notably, novel ADE signals such as hepatobiliary injury, endocrine dysfunction, and thromboembolic events were observed in both databases. Subgroup analyses revealed sex- and age-specific ADE patterns, with younger patients and males showing distinct toxicity profiles. Sensitivity analysis excluding combination therapies confirmed the robustness of primary signals. TTO analysis revealed that most ADEs occurred within the first two months after pemetrexed initiation, with a median TTO of 27 days and a predominance of early failure patterns (Weibull β < 1), highlighting the importance of close monitoring during early treatment. Rare but severe ADEs, including myocarditis, sepsis, cholestasis, and pseudocellulitis, were identified, several of which are not currently listed in official drug labeling. This study provides a comprehensive safety assessment of pemetrexed, confirming known toxicities and identifying new safety signals. Continuous pharmacovigilance is essential to optimize its clinical use and improve patient safety.

Specific Cardiovascular Mortality in Cancer Survivors: A Nationwide Population-Based Cohort Study in Japan

BACKGROUND

Improvements in cancer survivorship have led to concern about cardiovascular disease (CVD) among cancer survivors. This study aimed to investigate CVD mortality in patients with cancer compared with the general population, with a focus on specific CVDs including ischemic heart disease, heart failure, aortic dissection, ischemic stroke, and hemorrhagic stroke.

METHODS

This nationwide population-based cohort study used data from the National Cancer Registry in Japan. Patients diagnosed with cancer between January 2016 and December 2019 were included. Standardized mortality ratios (SMRs) and their 95% CIs were calculated to compare the risk of CVD mortality between patients with cancer and the general population. The SMRs were also computed for each specific CVD.

RESULTS

The study included 3 972 603 patients, representing 6 212 672 person-years of follow-up. Patients with cancer had a 2.39-fold higher risk of cardiovascular death compared with the general population. The SMR was highest for nonlymphoid hematologic malignancies (4.32 [95% CI, 4.15-4.50]). The mortality risk varied across specific types of CVD. Nonlymphoid hematologic malignancies had the highest SMRs for ischemic heart disease (3.15 [95% CI, 2.87-3.45]) and heart failure (7.65 [95% CI, 7.07-8.27]). The SMR for aortic dissection, ischemic stroke, and hemorrhagic stroke were highest for laryngeal (3.31 [95% CI, 2.29-4.79]), pancreatic (5.39 [95% CI, 4.79-6.05]), and liver (3.75 [95% CI, 3.36-4.18]) cancers, respectively.

CONCLUSIONS

Patients with cancer had a higher CVD mortality risk, which was prominent in nonlymphoid hematologic malignancies. The mortality risk varied considerably by cancer type and specific CVD type.

Enhancing prediction of thrombosis associated with breast cancer using prechemotherapy hematologic and coagulation characteristics

INTRODUCTION

The applicability of venous thromboembolism (VTE) risk assessment models (RAMs), to breast cancer (BC) populations remains unclear. We aimed to compare the efficacy of current RAMs and examine the potential of additional hematologic parameters and thromboelastography (TEG); a point of care test, in improving VTE prediction in breast cancer (BC) patients.

METHODS

In this pilot study, female BC patients were recruited before chemotherapy and followed for 6-12 months for VTE. VTE risk was assessed using Khorana score, Vienna CATS, PROTECHT, COMPASS-CAT, New Vienna CATSCORE, MDACC CAT, and hypercoagulability status. TEG and hematologic parameters were analyzed, and a modified RAM was developed.

RESULTS

Among 47 patients, 5 (10.6%) developed VTE. PROTECHT was the strongest predictor [area under the curve (AUC) = 0.844], followed by Vienna CATS (AUC = 0.781). Adding immature granulocytes and red blood cell count to PROTECHT optimized prediction (AUC = 0.856).

CONCLUSION

Incorporating hematologic parameters into PROTECHT may improve VTE risk prediction in BC patients, warranting further evaluation in larger studies.

A coagulation-related long non-coding RNA signature to predict prognosis and immune features of breast cancer

Breast cancer (BC) remains one of the most common malignancies among women worldwide, with persistently poor prognosis despite advancements in diagnostics and therapies. Long non-coding RNAs (lncRNAs) and coagulation-related genes (CRGs) are increasingly recognized for their roles in prognosis and immune modulation. Using transcriptomic data from 1,045 BC patients in TCGA, we identified CRG-associated lncRNAs via coexpression analysis (Pearson |R|> 0.4, p < 0.001) and constructed a prognostic model through univariate Cox analysis, LASSO regression with tenfold cross-validation (λ = 0.05), and multivariate Cox analysis. The model stratified patients into high- and low-risk groups with distinct overall survival (HR = 3.21, p < 0.001) and demonstrated robust predictive accuracy (AUC = 0.795 at 1 year). Functional enrichment revealed immune-related pathways (e.g., cytokine signaling, PD-L1 regulation), and high-risk patients exhibited elevated tumor mutational burden (TMB) and PD-L1 expression, suggesting enhanced immunotherapy responsiveness. Drug sensitivity analysis identified 5 targeted agents (e.g., BIBW2992) with differential efficacy between risk groups. This CRG-lncRNA signature provides a novel tool for prognosis prediction and personalized immunotherapy in BC, illuminating crosstalk between coagulation and immune pathways.

Incidence and risk of arterial thromboembolism in cancer patients from a safety-net healthcare system

BACKGROUND

The incidence of and risk factors for arterial thromboembolism (ATE) in patients with cancer, particularly in those with low socioeconomic status, remains understudied.

OBJECTIVES

We aimed to report the association between cancer-related and cardiovascular (CV) risk factors and the development of ATE.

METHODS

We performed a retrospective cohort study of patients with newly diagnosed invasive cancer from 2011 to 2021 at a safety-net hospital system. We ascertained ATE outcomes using validated inpatient billing diagnosis codes for myocardial infarction and ischemic stroke. We examined the incidence of ATE after cancer diagnosis using the cumulative incidence competing risk method to account for early mortality and estimated subdistribution hazard ratios for ATE using multivariable Fine-Gray models.

RESULTS

Among 17 236 patients (45.4% male, median 56 years), the ATE incidence was 1.5% (95% CI, 1.3%-1.6%) at 1 year and 2.8% (95% CI, 2.5%-3%) at 5 years after cancer diagnosis. In unadjusted analysis, the 5-year ATE incidence was highest in hematologic malignancies, such as multiple myeloma (8.6%) and acute leukemia (7.8%), among patients receiving immune checkpoint inhibitors (8.3% vs 2.7%), those with poor Eastern Cooperative Oncology Group performance status (5.4% performance status 4 vs 2.2% performance status 0), and advanced stage (3.1% IV vs 1.9% I). After multivariable adjustment, only cancer type remained significantly associated with ATE along with known CV risk factors, including advanced age, smoking, diabetes, hypertension, history of myocardial infarction, and history of ischemic stroke.

CONCLUSION

Both cancer type and traditional CV risk factors are independently associated with the development of ATE in patients with cancer.

Scoring systems to predict thrombotic complications in solid tumor patients

PURPOSE OF REVIEW

To explore the use of large datasets in predicting and managing cancer-associated venous thromboembolism (CAT) by stratifying patients into risk groups. This includes evaluating current predictive models and identifying potential improvements to enhance clinical decision-making.

RECENT FINDINGS

Cancer patients are at an elevated risk of developing venous thromboembolism (VTE), which significantly impacts mortality and quality of life. Traditional approaches to risk assessment fail to account for the procoagulant changes associated with cancer, making individualized risk prediction a challenge. Current clinical guidelines as per ASCO recommend risk assessment before chemotherapy and endorse thromboprophylaxis as a standard preventive measure. Since any cancer population is highly heterogeneous in terms of VTE risk, predicting the risk of CAT is an oncological challenge. To address this, different predictive models have been developed to stratify patients by risk, enabling targeted thromboprophylaxis. However, these models vary in accuracy and utility. The present review discusses the pros and cons of these different models.

SUMMARY

The review examines existing CAT risk prediction models, highlighting their strengths, limitations, and diagnostic performance. It also identifies additional variables that could enhance these models to improve their effectiveness in guiding clinicians toward better risk stratification and treatment decisions for cancer patients.

Challenges and Opportunities of Direct Oral Anticoagulant (DOAC) Therapy in Complex Clinical Scenarios: A Comprehensive Review and Practical Guide

Direct oral anticoagulants (DOACs) have emerged as a preferred alternative to vitamin K antagonists (VKAs) for the prevention and treatment of thromboembolic disorders, offering improved safety, predictable pharmacokinetics, and ease of administration. Despite these advantages, their use in complex clinical scenarios presents significant challenges that necessitate individualized therapeutic strategies. This comprehensive review explores the efficacy, safety, and limitations of DOAC therapy in special populations, including patients with renal or hepatic impairment, obesity, cancer-associated thrombosis, and antiphospholipid syndrome. Additionally, we examine their role in uncommon thrombotic conditions such as superficial venous thrombosis, embolic stroke of undetermined source, upper extremity vein thrombosis, inferior vena cava thrombosis, pelvic vein thrombosis, and cerebral vein thrombosis. The pharmacokinetic variability of DOACs in renal and hepatic dysfunction requires caution to balance the bleeding and thrombotic risks. In obesity, altered drug distribution and metabolism raise concerns regarding appropriate dosing and therapeutic efficacy. Cancer-associated thrombosis presents a complex interplay of prothrombotic mechanisms, necessitating careful selection of anticoagulant therapy. Furthermore, the use of DOACs in antiphospholipid syndrome remains controversial due to concerns about recurrent thrombotic events. Finally, in some unusual scenarios like inferior vena cava, pelvic vein, and cerebral vein thrombosis, the use of DOACs has scarce evidence. This review aims to guide clinicians in optimizing anticoagulation management in challenging patient populations by synthesizing current evidence and providing practical recommendations.

Initiating or Resuming Cancer Treatment After Ischemic Stroke and Clinical Outcomes

BACKGROUND AND OBJECTIVES

Patients with acute ischemic stroke (AIS) and active cancer (AC) are at high risk of mortality and stroke recurrence. While cancer characteristics are key prognostic factors, the impact of initiating or resuming active cancer treatment (ACT) after AIS remains unclear. This study aimed to estimate the proportion of patients initiating or resuming ACT after AIS and evaluate their clinical characteristics and outcomes.

METHODS

Using 2003-2021 data from the Acute STroke Registry and Analysis of Lausanne, we retrospectively analyzed patients with AC who initiated or resumed ACT within 3 months of index AIS vs those who did not. Exclusion criteria included patients with no or inactive cancer, insufficient data on ACT, and posthospitalization cancer diagnoses and those who died or entered palliative care before decisions on ACT. Outcomes included the modified Rankin Scale (mRS) score, mortality, and cerebrovascular recurrences at 3 and 12 months. Analyses comprised multivariable regressions, adjusting for prognostic variables, and propensity score matching (PSM).

RESULTS

Among 6,686 patients with AIS, 260 had AC and met eligibility criteria, with 117 (45%) initiating or resuming ACT. The median age was 73 years (interquartile range 16-5); 101 (39%) were women. Chemotherapy was the most prescribed ACT. Lower stroke severity was associated with initiating or resuming ACT (adjusted odds ratio [aOR] 0.93, 95% CI 0.88-0.98). Initiating or resuming ACT was associated with reduced mortality at 3 months before (adjusted hazard ratio [aHR] 0.39, 95% CI 0.28-0.56) and after (aHR 0.33, 95% CI 0.13-0.80) PSM and at 12 months before PSM (aHR 0.81, 95% CI 0.67-0.98). Mortality at 12 months after PSM (aHR 0.73, 95% CI 0.45-1.20), mRS scores at 3 months (aOR 0.96, 95% CI 0.58-1.59) and 12 months (aOR 0.66, 95% CI 0.36-1.19), and cerebrovascular recurrence risk at 3 months (subdistribution hazard ratio [sHR] 0.69, 95% CI 0.28-1.69) and 12 months (sHR 0.71, 95% CI 0.28-1.78) remained similar across groups before and after PSM.

DISCUSSION

In a nearly 2-decade stroke registry, almost half of the patients with AC initiated or resumed ACT within 3 months after AIS, with reduced medium-term and potentially long-term mortality but no differences in functional outcomes or cerebrovascular recurrence risk.

Khorana risk score in lung cancer patients treated with immune checkpoint inhibitors: a real-world study

BACKGROUND

Lung cancer patients are at increased risk of venous thromboembolism (VTE) and arterial thrombosis, particularly when treated with immune checkpoint inhibitors (ICIs). The Khorana Risk Score (KRS), an effective tool for predicting VTE risk in chemotherapy recipients, needs further validation in lung cancer patients treated with ICIs.

METHODS

We utilized a global database and conducted a retrospective cohort study. Lung cancer patients receiving ICIs were classified into intermediate (KRS 1-2) and high-risk (KRS ≥ 3) groups. The primary outcome was VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE); secondary outcomes included arterial thrombosis and all-cause mortality. Risk comparisons were performed using Cox proportional hazards analysis.

RESULTS

Among 5,378 patients, those with a high KRS had a greater risk of VTE (HR: 1.38, 95% CI: 1.15-1.65), including DVT (HR: 1.43, 95% CI: 1.12-1.82) and PE (HR: 1.32, 95% CI: 1.05-1.67). High KRS was also associated with increased arterial thrombosis (HR: 1.60, 95% CI: 1.29-1.96), ischemic stroke (HR: 1.73, 95% CI: 1.32-2.25), and elevated mortality (HR: 1.66, 95% CI: 1.48-1.87).

CONCLUSION

A high KRS (≥ 3) is associated with a higher risk of thrombotic events and mortality in lung cancer patients treated with ICIs. These findings suggest that KRS may aid risk stratification in this population, warranting further prospective research.

Prediction model of gastrointestinal tumor malignancy based on coagulation indicators such as TEG and neural networks

Objectives

Accurate determination of gastrointestinal tumor malignancy is a crucial focus of clinical research. Constructing coagulation index models using big data is feasible to achieve this goal. This study builds various prediction models through machine learning methods based on the different coagulation statuses under varying malignancy levels of gastrointestinal tumors. The aim is to use coagulation indicators to predict the malignancy of gastrointestinal tumors, expand the methods and ideas for coagulation index tumor prediction, and identify independent risk factors for gastrointestinal tumor malignancy.

Methods

Clinical data of 300 patients with gastrointestinal diseases were collected from the Second Affiliated Hospital of Anhui Medical University from January 2024 to August 2024 and grouped according to TNM and G staging, representing tumor malignancy levels. First, independent influencing factors of gastrointestinal tumor malignancy were identified using stepwise multivariate logistic regression. ROC curves were used to assess the ability of TEG five items and other coagulation indicators to distinguish between malignancy levels of gastrointestinal tumors. Finally, we constructed a network model suitable for our task data based on residual networks, named the Residual Fully Connected Binary Classifier (RFCBC). This model was compared with other commonly used binary classification methods to select the optimal model.

Results

The TEG five items (AUC values: R: 0.682; K: 0.731; α-angle: 0.736; MA: 0.699; CI: 0.747) showed better discrimination ability in the G group than other coagulation indicators. Although the TNM group showed moderate discrimination ability, it did not exhibit a significant advantage over other indicators. The R and MA values were identified as independent influencing factors in both TNM and G groups. Ultimately, the RFCBC prediction model showed the best predictive performance compared to other binary classification machine learning models (TEG five items: 87.56%; Thromboelastogram et al.: 88.6%).

Conclusion

This study found that the R and MA values are independent predictive factors for the malignancy of gastrointestinal tumors. Compared to other coagulation indicators, the TEG five items have better discrimination ability regarding tumor malignancy. The RFCBC model created in this study outperforms other commonly used binary classification methods in predicting the malignancy of gastrointestinal tumors, providing a new model construction method and feasible approach for future coagulation index prediction of gastrointestinal tumor malignancy.

Cancer, genetic susceptibility and risk of coronary artery disease: A prospective study

Objective

Cancer survivors have an increased risk of developing coronary artery disease (CAD). We introduce CAD polygenic risk scores (PRS) and examine associations with cancer status on CAD outcomes.

Methods

From the UK Biobank, we identified cancer survivors and CAD outcomes among 464,193 CAD-free participants using linked cancer registries, hospitalizations, and death records. CAD-PRS was categorized as low (lowest tertile), intermediate (tertile 2), and high (highest tertile). Adjusted Cox models assessed the joint and interaction effects of cancer status and CAD-PRS on CAD outcomes.

Results

Over the follow-up (median 11.7 years), 36,332 participants developed CAD. Compared to low CAD-PRS, the hazard ratios (HRs) and 95% confidence intervals (CIs) for CAD was 1.35 (1.31-1.38) for intermediate and 1.86 (1.81-1.91) for high CAD-PRS. The HR (95% CI) for CAD in cancer survivors was 1.16 (1.13-1.19) compared to those without cancer. In the joint effect analysis, compared to participants with low CAD-PRS and no cancer, the HRs (95% CIs) for CAD were 1.37 (1.32-1.41) and 1.90 (1.84-1.96) for intermediate and high CAD-PRS without cancer, respectively. For those with cancer, the HRs (95% CIs) were 1.26 (1.19-1.33), 1.59 (1.51-1.67), and 2.13 (2.03-2.23) for low, intermediate, and high CAD-PRS, respectively. A significant multiplicative interaction (HR: 0.94, 95% CI: 0.91-0.98) was observed between CAD-PRS and cancer status on CAD. Additionally, a significant additive interaction between cancer and high CAD-PRS was found for fatal CAD.

Conclusion

Cancer was associated with a higher risk of CAD and may further increase the risk of CAD related to genetic factors.

HMGB1 secretion by resveratrol in NSCLC: A pathway to ferroptosis-mediated platelet activation suppression

BACKGROUND

Cancer-associated venous thromboembolism (CAT) is a frequent and serious complication in cancer patients. Resveratrol, a natural compound with reported anti-tumor effects, is not fully understood in its role regarding CAT in lung cancer. This study aims to explore resveratrol's potential to diminish platelet activation induced by lung adenocarcinoma cells and uncover the underlying mechanisms.

METHODS

Clinical data on coagulation function in non-small cell lung cancer (NSCLC) patients were gathered. A549 human lung cancer cells and Lewis mouse lung cancer cells were employed to assess tumor-induced platelet activation and the impact of resveratrol on this process. Western blotting analyzed protein expression, electron microscopy examined extracellular vesicle (EV) morphology, flow cytometry measured platelet activation, reactive oxygen species (ROS), and exocrine protein expression, while ELISA quantified secretory proteins. Tumor control and platelet function were studied in tumor-bearing mice.

RESULTS

We identified that hematological profiles of NSCLC patients frequently manifest a hypercoagulable state relative to healthy controls and lung cancer cells could instigate platelet activation, yet resveratrol could attenuate this phenomenon induced by lung cancer. Resveratrol stimulates lung cancer cells to release HMGB1-enriched EVs, promoting platelet ferroptosis and inhibiting platelet activation through increased ROS, lipid peroxidation, and disrupted cystine transporters. In vivo studies confirm that resveratrol inhibits lung cancer cell growth and suppresses tumor-induced platelet activation in mice.

CONCLUSION

Our studies revealed that resveratrol alleviated lung cancer-induced ferroptosis associated platelet activation. This suggests a potential pharmacological approach for preventing and treating both lung cancer and CAT.

Application of thrombopoietic agents in cancer therapy-induced thrombocytopenia: A comprehensive review

Cancer therapy-induced thrombocytopenia (CT-IT) is one of the most common hematological toxicities of anti-cancer therapy, often leading to treatment dose reduced, postponed, or treatment plans altered or even discontinued. Thrombopoietin (TPO) is the only key regulatory factor in platelet production, and TPO receptor is considered an ideal target for the treatment of thrombocytopenia. Thrombopoietic agents, including recombinant human thrombopoietin (rhTPO) and thrombopoietin receptor agonists (TPO-RAs), bind to different regions of the TPO receptor, activating downstream signaling pathways to increase platelet levels. In recent years, numerous studies have demonstrated the effectiveness of thrombopoietic agents in the management of CT-IT. These agents can reduce bleeding risk, decrease platelet transfusions, and maintain relative dose intensity (RDI) of anti-cancer treatments. This article provides a review of the current progress in the application of thrombopoietic agents for CT-IT management.

Arterial thromboembolic events in testicular cancer patients: short- and long-term incidence, risk factors, and impact on mortality

BACKGROUND

Patients with testicular germ cell tumors (TGCT) have a high cancer-specific survival rate.

OBJECTIVES

We aimed to determine the short- and long-term risk of arterial thromboembolic events (ATE), their impact on mortality, and risk factors for ATE in TGCT patients.

METHODS

Patients with TGCT treated between 1994 and 2020 were included in a single-center retrospective cohort study. The primary outcome was ATE (ie, acute coronary syndrome, ischemic stroke, and acute peripheral arterial occlusion). Cumulative incidences were obtained in competing risk analysis. The impact of ATE on mortality was analyzed in a multistate model. Cox regression was used to explore short- and long-term ATE risk factors.

RESULTS

Overall, 1277 patients were included (median age, 35 years; seminoma: 56%; 44% cisplatin-based chemotherapy). Cumulative ATE incidences at 1, 10, and 25 years were 0.6% (95% CI, 0.3%-1.1%), 2.6% (95% CI, 1.8%-3.7%), and 12.0% (95% CI, 8.7%-15.9%), respectively. ATE diagnosis was independently associated with increased all-cause mortality (age-adjusted transition hazard ratio, 4.61; [95% CI, 2.40-8.85]; P < .001). Cisplatin-based chemotherapy was associated with ATE risk within 1 year after TGCT diagnosis (1.4% vs 0%, P < .001), whereas no differences were observed thereafter. Regarding long-term ATE risk, a point-based risk score was derived (age ≥ 35, smoking, and lactate dehydrogenase ≥ 250 IU/L), which efficiently stratified ATE risk (Harrel's C, 0.71 [95% CI, 0.63-0.78]), with cumulative ATE incidences in low-, intermediate-, and high-risk patients of 3.9%, 11.4%, and 22.7%, respectively.

CONCLUSION

ATE represents a common complication in TGCT survivors and is associated with increased mortality. A simple point-based score efficiently stratifies long-term ATE risk, whereas cisplatin-based chemotherapy increases short-term ATE risk.

Risk factors for venous thromboembolism in patients undergoing neoadjuvant chemotherapy as treatment for ovarian cancer

OBJECTIVE

During the treatment of ovarian cancer, the risk of venous thromboembolism (VTE) post operatively is well established, however, patients may be at even greater risk during neoadjuvant chemotherapy (NACT). This study aimed to determine the incidence and timing of VTE amongst patients undergoing NACT, whether there was an association with survival, and examine risk factors associated with the development of VTE.

STUDY DESIGN

This was a retrospective cohort study of patients diagnosed with ovarian, fallopian tube and primary peritoneal cancer receiving neoadjuvant chemotherapy betweenApril 2011 and April 2022 at a gynaecological cancer centre in England. Clinical factors examined included: age at diagnosis, Body Mass Index (BMI), presence of inflammatory co-morbidity, tumour morphology, stage of disease, pelvic mass,ascites,retroperitoneal lymphadenopathy, Khorana score, serum albumin levels, chemotherapy regime, bevacizumab administration and Ca 125 levels.

RESULTS

Of 304 patients analysed, 73 (24%) patients developed venous thromboembolism. Of the patients who developed VTE, fifty-five patients developed pulmonary embolism (75%) and the stage of treatment at which most VTEs were diagnosed was neoadjuvant chemotherapy (32%). There was no correlation observed, between the incidence of VTE and any risk factors, including Khorana score, with the exception of low albumin (<35 g/L)(odds ratio (OR):2.1(95%CI 1.1-3.9; p = 0.06) and patients who did not receive paclitaxel chemotherapy (OR:2.04(95%CI 1.02-4.05; p = 0.08). There was no difference in survival rates between the VTE group and the non-VTE group.

CONCLUSION

This study demonstrates high rates of VTE, especially pulmonary embolism, in ovarian cancer patients undergoing NACT. The present study, amongst others in the literature also suggest that the risk of VTE in ovarian cancer patients undergoing NACT is underestimated by current risk stratification models. Therefore, prospective trials dedicated to ovarian cancer patients specifically, and a development of a risk model that takes into account factors established by higher levels of evidence, are strongly recommended.

Cardio-Oncology and Heart Failure: a Scientific Statement From the Heart Failure Society of America

Heart failure and cancer remain 2 of the leading causes of morbidity and mortality, and the 2 disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnoses and cancer survivors. Risk stratification, monitoring and management of cardiotoxicity are presented across stages A through D heart failure, with focused discussion on heart failure with preserved ejection fraction and special populations, such as survivors of childhood and young-adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary-team approach and critical collaboration among heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Emerging advances in drug delivery systems (DDSs) for optimizing cancer complications

The management and treatment of tumor complications pose continuous challenges due to the inherent complexity. However, the advent of drug delivery systems (DDSs) brings promising opportunities to address the tumor complications using innovative technological approaches. This review focuses on common oncological complications, including cancer thrombosis, malignant serous effusion, tumor-associated infections, cancer pain, and treatment-related complications. Emphasis was placed on the application and potential of DDSs in mitigating and treating these tumor complications, and we delved into the underlying mechanisms of common cancer-associated complications, discussed the limitations of conventional treatments, and outlined the current status and potential development of DDSs for various complications in this review. Moreover, we have discussed the existing challenges in DDSs research, underscoring the need for addressing issues related to biocompatibility and targeting of DDSs, optimizing drug delivery routes, and enhancing delivery efficiency and precision. In conclusion, DDSs offer promising avenues for treating cancer complications, offering the potential for the development of more effective and safer drug delivery strategies, thereby improving the quality of life and survival rates of cancer patients.

Pharmacovigilance insights into medication-induced risk of dural arteriovenous fistula

BACKGROUND

Dural arteriovenous fistulas (DAVFs) pose a significant health threat owing to their high misdiagnosis rate. Case reports suggest that DAVFs or related acute events may follow medication use; however, drug-related risk factors remain unclear. In clinical practice, the concomitant use of multiple drugs for therapy is known as "polypharmacy situations," further increasing the risk of drug-induced DAVF. Real-world studies linking medications and DAVF can alert clinicians to their possibilities and contribute to clinical decision-making and patient education.

METHOD

This study investigated adverse events spanning a decade from the FAERS database, employing pharmacovigilance analysis to systematically assess the risk of drug-induced DAVF. Furthermore, the clinical characteristics of these drug-related DAVFs, such as demographic information, complications, and outcomes, were characterized.

RESULT

This study generated a broad spectrum of drugs associated with DAVFs. A total of 355 DAVF events, involving 161 drugs across 73 categories, were compiled from millions of records. We identified eight classes of drugs for thorough investigation. Pharmacovigilance analysis revealed that tamoxifen, methylprednisolone, betamethasone, prednisone, rebif, ustekinumab, natalizumab, baclofen, dabigatran etexilate, and bupivacaine have the potential to induce DAVFs. Cerebrovascular thrombotic and embolic events emerge as the most prominent co-adverse events of drug-induced DAVFs. Analyses based on drug-disease targets suggested that the regulation of angiogenesis could be a potential mechanism in tamoxifen-induced DAVFs. Apart from medications with gender-specific prescription patterns, most medications exhibit a high risk of DAVF in adult male cohorts. Five patients with drug-related DAVFs experienced severe (fatal) outcomes, with four reports attributed to tamoxifen.

CONCLUSION

These findings highlight the diverse range of drugs implicated in the occurrence or progression of DAVF. Drugs such as tamoxifen, corticosteroids, multiple sclerosis medications, and oral anticoagulants require particular attention. Future research should focus on elucidating the underlying mechanisms and risk factors, such as thrombosis, contributing to drug-induced DAVF to inform preventive strategies and optimize patient care.

A meta-analysis on the impact of concurrent or pre-existing cancer diagnosis on acute myocardial infarction outcomes

BACKGROUND

There is still a significant gap in understanding the impact of concomitant or previous cancer diagnoses on clinical outcomes of acute myocardial infarction (AMI).

OBJECTIVE

To provide updated evidence on the effect of concomitant or previous cancer diagnoses on mortality and risk of complications, specifically major bleeding, myocardial reinfarction, and stroke, of patients with AMI.

METHODS

A literature search was conducted across PubMed, EMBASE, and Scopus databases. English-language cohort studies published in peer-reviewed journals were included. Pooled effect estimates were calculated using random-effects models and reported as odds ratio (OR) or hazards ratio (HR) with 95% confidence intervals (CI). The certainty of the evidence was assessed using the standard GRADE approach.

RESULTS

A total of 22 studies were included. AMI patients with previous or concurrent cancer had increased risk of in-hospital mortality (OR 1.44, 95% CI: 1.20, 1.73), in-hospital mortality related to cardiovascular complications (OR 2.06, 95% CI: 1.17, 3.65), mortality at 30-days follow up (OR 1.47, 95% CI: 1.24, 1.74) and mortality at 1 year follow up (HR 2.67, 95% CI: 1.73, 4.11), compared to patients without cancer. The risk of major bleeding (OR 1.74, 95% CI: 1.40, 2.16), reinfarction (OR 1.20, 95% CI: 1.05, 1.37), and stroke (OR 1.16, 95% CI: 0.99, 1.37) was also higher in patients with previous or concurrent cancer. The certainty of evidence was rated as "low" for all outcomes, except for the risk of major bleeding, which was rated as "very low."

CONCLUSION

Based on the low to very low certainty of evidence, we conclude that the presence of previous cancer diagnosis or concurrent cancer may increase the risk of adverse outcomes in patients with AMI. Early interventions, such as close monitoring of cardiac function, lifestyle modifications, and targeted pharmacological therapies, might help mitigate the risk of AMI and improve overall clinical outcomes. However, further methodologically rigorous studies are needed to validate the findings of this review.

Risk assessment and prevention of cancer-associated venous thromboembolism in ambulatory patients with solid malignancies

Venous thromboembolism remains a major cause of morbidity and mortality among ambulatory cancer patients, necessitating effective risk assessment and prevention strategies. Despite the availability of risk assessment models and guidelines recommending primary thromboprophylaxis with low-molecular-weight heparins or direct oral anticoagulants, the application of these strategies is inconsistent. This review provides an overview of the current state-of-the-art venous thromboembolism risk assessment and thromboprophylaxis in ambulatory patients with cancer, focusing on existing risk assessment models and the latest guideline recommendations. Finally, it summarizes gaps in knowledge, discusses future directions, and highlights recent advances and state-of-the-art research presented at the 2024 International Society on Thrombosis and Haemostasis Congress in Bangkok, Thailand.

Assessment of Hypercoagulability in Splanchnic Vein Thrombosis by Measurement of the Hemostasis Enzymes Thrombin and Activated Protein C

Splanchnic vein thrombosis (SVT), which is particularly prevalent in myeloproliferative neoplasms (MPNs), has a multifactorial pathomechanism involving the anticoagulant protein C (PC) pathway. To better characterize the hypercoagulable state in SVT we assessed its key enzymes thrombin and activated PC (APC). The study population included 73 patients with SVT, thereof 36 MPN+, confirmed by bone marrow biopsy, 37 MPN-, and 30 healthy controls. Direct measurement of the active enzyme forms of thrombin and APC in the circulation was achieved by using oligonucleotide-based enzyme capture assays (OECA). Additionally, activation markers of coagulation and fibrinolysis were measured. Plasma levels of free thrombin and APC were higher in the MPN+ than in the MPN- cohort, with 0.49 vs. <0.46 pmol/L (p = 0.0057), respectively, 1.23 vs. 0.58 pmol/L (p = 0.0122), and in healthy controls (vs. <0.46 pmol/L, p = 0.0012; vs. 0.54 pmol/L, p = 0.0035). The indirect activation markers prothrombin fragment 1+2, thrombin-antithrombin complex, and D-dimer did not differ between groups. Receiver operating characteristic analysis suggested that SVT patients with MPN can be better distinguished by APC than by conventional indirect thrombin markers. A potential application of these biomarkers to guide anticoagulant therapy and to investigate the role of the PC pathway in MPN-associated hypercoagulability should be further studied.

Deep Vein Thrombosis as a Complication of Gemcitabine-Capecitabine Chemotherapy in Adenocarcinoma of Gallbladder

Gallbladder adenocarcinoma has a high mortality rate, with approximately 1.7% cancer-related deaths worldwide. Cancer-associated thrombosis (CAT), including deep vein thrombosis (DVT), can significantly increase the risk of mortality within cancer patients, especially in pancreatic, brain, and intra-abdominal cancers, as well as in advanced and metastatic cancers. In this case report, there was a 45-year-old male patient diagnosed with advanced gallbladder adenocarcinoma UICC stage IVB with a TNM stage of T2b, N0, M1 with liver metastases who experienced pain and swelling in both lower limbs after undergoing a VI-A cycle of chemotherapy with gemcitabine capecitabine. The risk of thrombosis was calculated using the modified Khorana-Vienna CAT scores, which increased during every chemotherapy session. In this case, the Khorana-Vienna CAT score was calculated during two latest cycle of chemotherapy that somewhat considered delayed as the patient had already shown hypercoagulopathy symptoms and developed a poorer prognosis. Early CAT scoring, ideally before starting chemotherapy session, potentially improves thrombosis prognosis. The patient's condition improved after administration of antithrombotic agents. Chemotherapy agents and other factors, including the cancer site and presence of metastatic cancer, influence the risk of CAT. Risk predictor scores are required to assess the risk of CAT and benefits of prophylactic treatment. Prophylactic therapy can be initiated in patients with high-risk CAT, calculated using the modified Khorana and Vienna CAT scores, to prevent thrombosis and improve patient outcomes.

Potential Player of Platelet in the Pathogenesis of Cardiotoxicity: Molecular Insight and Future Perspective

Cancer patients may encounter the onset of cardiovascular disease due to tumor advancement or chemotherapy, commonly known as "cardiotoxicity." In this respect, the conventional chemotherapy treatment protocol involves a mixture of different medications. These medications can be detrimental to cardiac tissue, consequently exposing the patient to the possibility of irreversible cardiac injury. The enhancement of oxidative stress and inflammation is an important mechanism of chemotherapeutic agents for developing cardiotoxicity. Regarding their dual pro- and anti-inflammatory functions, platelets can significantly influence the progression or suppression of cardiotoxicity. Therefore, the expression of platelet activatory markers can serve as valuable prognostic indicators for cardiotoxicity. The primary objective of this study is to examine the significance of platelets in cardiotoxicity and explore potential strategies that could effectively target malignant cells while minimizing their cytotoxic impact, such as cardiotoxicity and thrombosis.

Venous thromboembolism is associated with increased all-cause mortality in ALK-positive non-small cell lung cancer

BACKGROUND

Venous thromboembolic events (VTE) are often diagnosed in ALK-positive lung cancer although it has not been demonstrated how their co-occurrence affects patients' survival.

METHODS

The study included patients with ALK-positive lung cancer recognized in metastatic stage in the period 2017-2022. All received treatment with ALK inhibitors at The Maria Sklodowska-Curie National Research Institute of Oncology in Warsaw. The main aim of the study was to assess overall survival (OS) in relation to VTE occurrence. The additional purpose was to define predictors of VTE and OS.

RESULTS

The study included 54 patients in median age 60 years, men were a minority (25 / 46.3%). VTE was diagnosed in 12 (22.2%) patients: 9 (16.7%) cases with pulmonary embolism (PE), 2 cases with thrombosis in vena cava superior, one case with deep vein thrombosis and thrombosis in vena cava inferior. Among patients with PE: 2 patients died directly due to the first PE episode and one due to a recurrent PE. Patients with VTE had significantly shorter overall survival (median 11.7 vs. 37.4 months, log-rank test p = 0.003). The risk of all-cause mortality was increased significantly in both: VTE (HR = 3.47; 95%CI: 1.61-7.49; p = 0.0016) or alone PE (HR = 2.41; 95%CI: 1.06-5.50; p = 0.037). The risk of VTE diagnosis was significantly increased during active treatment with crizotinib (HR = 8.72; p = 0.0004) or alectinib (HR = 21.47; p = 0.000002). Metastases to liver and baseline leukocyte count > 11 × 10⁹/L were significant predictors of VTE and OS. Khorana score ≥ 3 points predicted OS (HR = 2,66; 95%CI: 1,05-6,75; p = 0,04), but remained insignificant for VTE.

CONCLUSION

The diagnosis of any type of VTE or alone PE was associated with significantly worse overall survival in patients with ALK-positive non-small cell lung cancer.

Thromboembolism during immune checkpoint inhibitor therapy: frequency and risk factors

BACKGROUND

Thromboembolism (TE) is a well-known complication during chemotherapy in cancer patients. However, the risk of TE associated with immune checkpoint inhibitors (ICIs) is unknown. This study was performed to investigate the incidence of TE and associated risk factors in patients treated with ICIs.

METHODS

We conducted a retrospective chart survey of patients receiving at least one ICI at Shinshu University Hospital between September 2014 and October 2021. Age, sex, cancer type, body mass index, medical history, laboratory data at commencement of treatment, and medication data were obtained from electronic medical records. TE events (venous thromboembolism [VTE], arterial thromboembolism [ATE]) were identified after ICI initiation.

RESULTS

The study population consisted of 548 patients with a median age of 70.0 (19-89) years, 71.4% men, and a median follow-up of 15.1 months (range; 0.16-72.0 months). Nivolumab was the most commonly used ICI (45.8%), followed by pembrolizumab (23.9%), pembrolizumab plus anticancer drugs (7.8%), and nivolumab plus ipilimumab (5.1%). Thirty-eight cases of TE (6.9%) occurred (22 VTE, 16 ATE). Risk factors significantly associated with TE in multivariate logistic analysis were dyslipidemia (OR 2.44; 95% CI 1.17-5.09; p = 0.017), Khorana score ≥ 2 (HR 2.40; 95% CI 1.14-5.04; p = 0.021). Overall survival was not significantly different from patients without TE (p = 0.963).

CONCLUSION

These results suggested that the frequency of TE is higher than expected and should be considered and monitored in patients treated with ICIs.

Time Relationship between the Occurrence of a Thromboembolic Event and the Diagnosis of Hematological Malignancies

OBJECTIVES

Venous and arterial thromboembolism (VTE/ATE) often coexist with onco-hematologic diagnosis. This study aimed to assess the time relationship between the diagnosis of VTE/ATE and blood cancers. The second aim was to identify VTE/ATE risk factors related to the type of hematology disease and cardiac history.

METHODS

A total of 1283 patients underwent cardio-oncology evaluation at the Institute of Hematology and Transfusion Medicine in Warsaw from March 2021 through March 2023 (2 years), and 101 (7.8%) cases were identified with VTE/ATE.

RESULTS

ATE compared with VTE significantly occurred more often before the diagnosis and treatment of hematologic malignancy: 33/47 (70.2%) vs. 15/54 (27.8%), p < 0.0001. The risk of a VTE episode is exceptionally high in the first months after the diagnosis of an onco-hematological disease and the initiation of anticancer treatment. The higher frequency of VTE was associated with acute myeloid leukemia (17 cases/270 patients/6.30%/p = 0.055), acute lymphocytic leukemia (7 cases/76 patients/9.21%/p = 0.025), and chronic myeloproliferative disease (7 cases/48 patients/14.58%/p = 0.0003). Only the risk of VTE was significantly increased before (OR = 6.79; 95% CI: 1.85-24.95; p = 0.004) and after diagnosis of myeloproliferative disease (OR = 3.12; 95% CI: 1.06-9.16; p = 0.04).

CONCLUSIONS

ATEs occur more often than VTE before a diagnosis of blood cancer. The risk of VTE is exceptionally high before and after diagnosis of chronic myeloproliferative disease.

How Protein Depletion Balances Thrombosis and Bleeding Risk in the Context of Platelet's Activatory and Negative Signaling

Platelets are small cell fragments that play a crucial role in hemostasis, requiring fast response times and fine signaling pathway regulation. For this regulation, platelets require a balance between two pathway types: the activatory and negative signaling pathways. Activatory signaling mediators are positive responses that enhance stimuli initiated by a receptor in the platelet membrane. Negative signaling regulates and controls the responses downstream of the same receptors to roll back or even avoid spontaneous thrombotic events. Several blood-related pathologies can be observed when these processes are unregulated, such as massive bleeding in activatory signaling inhibition or thrombotic events for negative signaling inhibition. The study of each protein and metabolite in isolation does not help to understand the role of the protein or how it can be contrasted; however, understanding the balance between active and negative signaling could help develop effective therapies to prevent thrombotic events and bleeding disorders.

Complication Rates of Peripherally Inserted Central Catheters in Oncologic Versus Non-Oncologic Patients

OBJECTIVES

Peripherally inserted central catheters are commonly used in cancer patients and provide vascular access for the administration of chemotherapy, antibiotics, or parenteral nutrition. Besides many advantages, they represent a source of possible complications such as catheter related blood stream infection, catheter occlusion, or thrombosis. In this study, the catheter-related complication rate between oncologic and non-oncologic patients was compared.

METHODS

This retrospective cohort-study included 411 patients who underwent their first catheter placement at the Vienna General Hospital-Medical University of Vienna from January 2013 to June 2018. Patient demographics and catheter-related parameters were collected and statistically analyzed using a competing risk model.

RESULTS

Mean catheter dwell time was 27.75 days. The overall complication rate was 7.54% (2.72 per 1000 catheter days). Underlying malignant disease (hazard ratio: 0.351, 95% confidence interval [CI]: 0.133-0.929, P = .035) and chemotherapy administration (hazard ratio: 2.837, 95% CI: 1.088-7.394, P = .033) were significantly associated with the occurrence of any kind of complication. Catheter related blood stream infection was observed among 11 (2.68%) patients and again significantly associated with chemotherapy administration (hazard ratio: 4.545, 95% CI: 1.178-17.539; P = .028). Thrombosis was found in 7 (1.70%) patients and occlusion in 13 (3.16%) cases.

CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE

Choice of venous access is an interdisciplinary decision with emphasis on patient participation. In oncologic patients, our data suggests that the benefits of peripherally inserted central catheters regarding costs, invasiveness, and accessibility might be outweighed by the higher rate of complications associated with the device. This becomes even more important in a community care setting, where standardized handling procedures and patient education play a pivotal role in device safety.

Cancer Therapy and Exercise Intolerance: The Heart Is But a Part: JACC: CardioOncology State-of-the-Art Review

The landscape of cancer therapeutics is continually evolving, with successes in improved survivorship and reduced disease progression for many patients with cancer. Improved cancer outcomes expose competing comorbidities, some of which may be exacerbated by cancer therapies. The leading cause of disability and death for many early-stage cancers is cardiovascular disease (CVD), which is often attributed to direct or indirect cardiac injury from cancer therapy. In this review, the authors propose that toxicities related to conventional and novel cancer therapeutics should be considered beyond the heart. The authors provide a framework using the oxygen pathway to understand the impact of cancer treatment on peak oxygen uptake, a marker of integrative cardiopulmonary function and CVD risk. Peripheral toxicities and the impact on oxygen transport are discussed. Consideration for the broad effects of cancer therapies will improve the prediction and identification of cancer survivors at risk for CVD, functional disability, and premature mortality and those who would benefit from therapeutic intervention, ultimately improving patient outcomes.

Underlying Mechanisms of Thrombosis Associated with Cancer and Anticancer Therapies

Cancer-associated thrombosis (CAT) has been identified as the second most prevalent cause of death after cancer itself. Moreover, the risk of thrombotic events in cancer patients increases due to anticancer drugs, such as tyrosine kinase inhibitors (TKIs). Venous thromboembolism (VTE) as well as arterial thromboembolic (ATE) events are present in CAT. Although VTE occurs more frequently, ATE events are very significant and in some cases are more dangerous than VTE. Guidelines for preventing thrombosis refer mainly VTE as well as the contribution of ATE events. Several factors are involved in thrombosis related to cancer, but the whole pathomechanism of thrombosis is not clear and may differ between patients. The activation of the coagulation system and the interaction of cancer cells with other cells including platelets, endothelial cells, monocytes, and neutrophils are promoted by a hypercoagulable state caused by cancer. We present an update on the pathomechanisms of CAT and the effect of anticancer drugs, mainly targeted therapies with a focus on TKIs. Considering the risk of bleeding associated with anticoagulation in each cancer patient, the anticoagulation strategy may involve the use of FXIa inhibitors, direct oral anticoagulants, and low-molecular-weight heparin. Further research would be valuable in developing strategies for reducing CAT.

Arterial Thrombosis in Patients with Cancer

Patients with cancer are at increased risk of arterial thromboembolic disease due to the presence of risk factors common to both the development of cancer and arterial thrombosis, the cancer itself, and the treatments provided to treat cancer. We review here the epidemiology and pathophysiology of arterial thromboembolic disease in cancer, along with its prevention and treatment strategies. We also propose a generalized approach for the management of arterial thromboembolic disease in this patient population.

Cardiovascular comorbidities and their prognostic value in small cell lung cancer patients with chemoradiotherapy

BACKGROUND

Small cell lung cancer (SCLC) is an extremely malignant subtype of lung cancer because of its high potential for metastases. Cardiac invasion of SCLC is a serious concern that may lead to systemic embolism or tract obstruction. It has aroused much concern that cardiovascular comorbidities may significantly affect the survival of SCLC patients and their treatment decisions.

METHODS

We consecutively recruited 772 small cell lung cancer (SCLC) patients between January 2011 and December 2018 from 4 cancer specialty hospitals in China. Only newly diagnosed primary cancer inpatients were included. Univariable and multivariable adjusted Cox proportional hazard models were conducted to evaluate the risk factors associated with mortality. Hazard ratios (HRs) for mortality and corresponding 95% confidence intervals (95% CIs) were calculated.

RESULTS

The prevalence of cardiovascular diseases (CVDs) was 34.6% in all SCLC patients. Log-rank analysis presented statistically significant differences in median survival time (MST) between patients with CVD and without CVD in all SCLC patients (9.0 months vs. 15.0 months, P = 0.005) and patients with chemotherapy only (12.0 months vs. 18.0 months, P = 0.048). Pericardial effusion (HR 1.671, 95% CI 1.082-2.580, P = 0.021) and heart failure (HR 1.752, 95% CI 1.290-2.379, P < 0.001) were independent risk factors associated with mortality in all SCLC patients. VTE is related to poorer prognosis in patients with chemotherapy only (HR 5.558, 95% CI 1.335-23.135, P = 0.018) and chemoradiotherapy (HR 3.057, 95% CI 1.270-7.539, P = 0.013).

CONCLUSIONS

Comprehensive management of CVD comorbidities is of vital importance for the long-term prognosis of SCLC patients.

Neoplastic pathologic hip fractures are associated with a higher risk of post-operative bleeding and thromboembolic events

INTRODUCTION

Surgical treatment of hip fractures leads to significant post-operative complications. Although pathologic fractures (PF) are associated with worse outcomes, most studies do not differentiate between etiology (neoplastic and non-neoplastic PF). We seek to compare 30-day complication rates between 1) native hip fractures and neoplastic PF, and 2) neoplastic and non-neoplastic PF.

MATERIALS AND METHODS

A total of 127,819 patients with hip fractures and 5104 with PF diagnosed from 2005 to 2021 were retrieved from the NSQIP database. We included 1843 patients with neoplastic PF and 3261 with non-neoplastic PF. Demographics, pre-operative labs and co-morbidities, and post-operative outcomes were analyzed. Propensity-score matching was conducted to control for confounders.

RESULTS

Patients with a neoplastic PF had a significantly higher rate of deep venous thrombosis (DVT) (4 % vs 1.2 %, p = 0.001) and pulmonary embolism (PE) (2.4 % vs 0.7 %, p < 0.001), than native hip fractures. Rates of post-operative bleeding were significantly higher in the neoplastic PF group (29.3 % vs 23.9 %, p < 0.001) than non-neoplastic PF. No differences in soft tissue complications were found. When comparing neoplastic and non-neoplastic PF, the former had a higher rate of PE (2.5 % vs 1.0 %, p = 0.015) and post-operative bleeding (27.6 % vs 22.0 %, p = 0.009). Unplanned readmission rates and 30-day mortality rate were also higher in the neoplastic PF group.

CONCLUSION

Neoplastic PF of the hip are associated with higher risk of thromboembolic event rates and post-operative bleeding than both native hip fractures and non-neoplastic PF. No differences in rates of soft tissue complications were found between groups.

Apoptotic cells promote circulating tumor cell survival and metastasis

During tumor progression and especially following cytotoxic therapy, cell death of both tumor and stromal cells is widespread. Despite clinical observations that high levels of apoptotic cells correlate with poorer patient outcomes, the physiological effects of dying cells on tumor progression remain incompletely understood. Here, we report that circulating apoptotic cells robustly enhance tumor cell metastasis to the lungs. Using intravenous metastasis models, we observed that the presence of apoptotic cells, but not cells dying by other mechanisms, supports circulating tumor cell (CTC) survival following arrest in the lung vasculature. Apoptotic cells promote CTC survival by recruiting platelets to the forming metastatic niche. Apoptotic cells externalize the phospholipid phosphatidylserine to the outer leaflet of the plasma membrane, which we found increased the activity of the coagulation initiator Tissue Factor, thereby triggering the formation of platelet clots that protect proximal CTCs. Inhibiting the ability of apoptotic cells to induce coagulation by knocking out Tissue Factor, blocking phosphatidylserine, or administering the anticoagulant heparin abrogated the pro-metastatic effect of apoptotic cells. This work demonstrates a previously unappreciated role for apoptotic cells in facilitating metastasis by establishing CTC-supportive emboli, and suggests points of intervention that may reduce the pro-metastatic effect of apoptotic cells.

GRAPHICAL ABSTRACT

Gynecological Cancer and Venous Thromboembolism: A Narrative Review to Increase Awareness and Improve Risk Assessment and Prevention

The prevention and appropriate management of venous thromboembolism in cancer patients is of paramount importance. However, the literature data report an underestimation of this major problem in patients with gynecological cancers, with an inconsistent venous thromboembolism risk assessment and prophylaxis in this patient setting. This narrative review provides a comprehensive overview of the available evidence regarding the management of venous thromboembolism in cancer patients, focusing on the specific context of gynecological tumors, exploring the literature discussing risk factors, risk assessment, and pharmacological prophylaxis. We found that the current understanding and management of venous thromboembolism in gynecological malignancy is largely based on studies on solid cancers in general. Hence, further, larger, and well-designed research in this area is needed.

Mechanical Venous Thrombectomy for Deep Venous Thrombosis in Cancer Patients: A Single-Center Retrospective Study

PURPOSE

Venous thromboembolism (VTE) is a major contributor to the mortality of cancer patients. Mechanical thrombectomy (MT) is an endovascular technique that physically removes a thrombus without thrombolytics. The purpose of this study was to evaluate safety, efficacy, and clinical outcomes following MT for lower extremity DVT in cancer patients.

METHODS

This single-center, retrospective study evaluated outcomes following MT of lower extremity DVT in cancer patients from November 2019 to May 2023. The primary outcome measure was clinical success, defined as a decrease in Villalta score by at least 2 points following the intervention. Secondary outcomes included repeat intervention-free survival and overall survival. Technical success was defined as restoring venous flow with mild (< 10%) or no residual filling defect.

RESULTS

In total, 90 patients and 113 procedures were included. Technical and clinical success was achieved in 81% and 87% of procedures performed. Repeat intervention-free survival at 1 month, 3 months, and 6 months post-procedure was 92%, 82%, and 77%, respectively. The complication rate was 2.7%. Pathologic analysis of the extracted thrombus revealed tumor thrombus in 18.4% (18/98) samples. Overall survival for the study cohort was 87% at 1 month, 74% at 3 months, and 62% at 6 months. Patients who were found to have tumor thrombi were noted to have a decreased overall survival compared to patients with non-tumor thrombi (P = 0.012).

CONCLUSION

MT is safe and efficacious in reducing cancer patients' VTE-related symptoms. The high rate of tumor thrombus in thrombectomy specimens suggests this phenomenon is more common than suspected.

Cancer patients and ischemic stroke

Patients with cancer have an increased risk of ischemic stroke compared to the general population. Additionally, these patients have a worse prognosis compared to stroke patients without cancer. Activation of coagulation appears to play a key role in the pathophysiology of ischemic stroke in patients with cancer. However, the underlying mechanisms remain unknown. Moreover, we do not have a way to identify cancer patients with a high risk of stroke and cannot develop prevention strategies. Therefore, there is an urgent need for neurologists and oncologists to develop screening and prevention strategies for stroke in patients with cancer. In this review, we summarize the characteristics of cancer patients at a high risk of stroke, the predictors for the development of stroke and survival in cancer patients, and possible treatments.

Emerging Trends in Left Ventricular Thrombus: A Comprehensive Review of Non-Ischemic and Ischemic Cardiopathies, Including Eosinophilic Myocarditis, Chagas Cardiomyopathy, Amyloidosis, and Innovative Anticoagulant Approaches

This comprehensive review explores the intricate aspects of left ventricular thrombus (LVT), a potential complication in both ischemic and non-ischemic cardiomyopathies. It provides a thorough understanding of left ventricular thrombus, revealing its uncommon incidence in the general population (7 cases per 10,000 patients), predominantly linked to ischemic heart diseases (ICMs) at an 80% prevalence rate. Diagnostic tools, notably transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR), demonstrate varying sensitivity but remain indispensable in specific clinical contexts related to LVT as non-invasive diagnostic modalities. A detailed comparison between ICM patients and those with non-ischemic cardiomyopathy (NICM) who have left ventricular thrombus reveals subtle distinctions with significant clinical implications. This analysis underscores the importance of these imaging techniques in distinguishing between the two conditions. Additionally, we explored the occurrence of LVT in specific non-ischemic cardiomyopathies, including Takotsubo syndrome, hypertrophic cardiomyopathy, eosinophilic myocarditis, Chagas disease, cardiac amyloidosis, and several other conditions. The article further delves into anticoagulation strategies, thoroughly examining their impact on LVT regression and patient outcomes. Pharmacological interventions, with a focus on direct oral anticoagulants, emerge as promising alternatives; however, there is insufficient information on their efficiency and safety, especially in NICM population. In conclusion, this review highlights the complex nature of LVT, incorporating a range of etiopathogenic factors, diagnostic complexities, and evolving therapeutic approaches. It emphasizes the pressing need for ongoing research in this field.

Research progress on venous thrombosis development in patients with malignant tumors

The coexistence of venous thromboembolism (VTE) within patients with cancer, known as cancer-associated thrombosis (CAT), stands as a prominent cause of mortality in this population. Over recent years, the incidence of VTE has demonstrated a steady increase across diverse tumor types, influenced by several factors such as patient management, tumor-specific risks, and treatment-related aspects. Furthermore, mutations in specific genes have been identified as potential contributors to increased CAT occurrence in particular cancer subtypes. We conducted an extensive review encompassing pivotal historical and ongoing studies on CAT. This review elucidates the risks, mechanisms, reliable markers, and risk assessment methodologies that can significantly guide effective interventions in clinical practice.

Arterial Thromboembolism in Japanese Patients With Cancer: Incidence, Predictors, and Survival Impact

Background

Thromboembolism is a significant complication for patients with cancer, leading to treatment interruptions and poor outcomes.

Objectives

The aim of this study was to investigate the incidence of arterial thromboembolism (ATE) within cancer populations, identify the predictors of ATE, and determine its survival impact.

Methods

A retrospective multicenter study was performed using data from the Osaka Cancer Registry linked with administrative data from 2010 to 2015. Patients were monitored for 5 years after cancer diagnosis, and ATE incidence was calculated with death as a competing risk. Fine and Gray competing risk regression models and Cox proportional hazards models were used to evaluate the predictors of ATE and the survival impact. Restricted mean survival time (RMST) was used to assess whether antithrombotic therapy after ATE contributed to improved survival.

Results

The cohort comprised 97,448 patients with cancer (42.3% women, median age 70 years). ATE incidence displayed an annual increase, peaking 1 year after cancer diagnosis (1-, 2-, 3-, 4-, and 5-year cumulative incidences were 1.29%, 1.77%, 2.05%, 2.22%, and 2.32%, respectively). Male sex, advanced age, advanced cancer stage, and hematologic malignancies correlated with a high risk for ATE. Patients with ATE had a 2-fold increased risk for mortality compared with those without ATE. The 90-day and 1-year RMST differences for those on antithrombotic therapy were 13.3 days (95% CI: 10.4-16.2 days; P < 0.001) and 57.8 days (95% CI: 43.1-72.5 days; P < 0.001), favoring the antithrombotic therapy group. The RMST differences varied by cancer stage.

Conclusions

The risk for ATE varies according to sex, age, and cancer progression and type. Antithrombotic therapy after ATE is associated with improved survival among patients with cancer.

Assessing hypercoagulability and VTE risk using thromboelastography and Khorana score in women with cancers receiving chemotherapy

Venous thromboembolism (VTE) is a common occurrence in cancer and chemotherapy increases thrombosis risk. Current risk assessment models such as the Khorana score (KS) and its modifications have limitations in female cancers. We assessed the coagulation profile of a group of women cancer patients under chemotherapy using thromboelastography (TEG) to determine if this can inform VTE risk assessment. Cancer patients who planned to receive chemotherapy were recruited. Baseline demographics, cancer data, BMI, Khorana Score (KS), and VTE risk factors were recorded and patients were followed for 6 months, for any thrombotic events. A total of 36 patients aged 35-85 (18 breast, 11 endometrial, 7 ovarian cancer) were evaluated. Hypercoagulability was detected in 63% of patients post-chemo cycle 1 and 75% post-cycle 2, with a significant increase in MA (maximum amplitude) and CI (clotting index), reduction in R (reaction time), K (clot kinetics), and LY30 (lysis time after 30 min of MA). KS showed only 7% of patients were high risk, 23% were low, and 70% were intermediate risk. MA and CI significantly increased in patients with intermediate and high-risk KS when compared with the low-risk patients and MA was positively correlated with KS. Five patients developed actual VTE; 100% of the tested ones were hypercoagulable either post-cycle 1 or 2 and 80% were KS intermediate risk. TEG is a hypercoagulability marker and TEG-MA and CI can potentially assess VTE risk. Larger studies are needed to assess the utility of TEG as an adjuvant to KS to better predict VTE in specific female cancers.

Platelet Parameters as Biomarkers for Thrombosis Risk in Cancer: A Systematic Review and Meta-analysis

Cancer-associated thrombosis (CAT) is a major cause of both morbidity and mortality in cancer patients. Platelet count has been investigated as a predictor of CAT in various settings while knowledge on platelet activation parameters is sparse. This report provides a systematic review and meta-analysis on available literature on associations between platelet count and/or function and arterial and venous thrombosis in adult cancer patients. The review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. PubMed and Embase were searched up to March 2022. The National Heart, Lung, and Blood Institute's tools were used for quality assessment. In total, 100 studies were included which investigated the association between CAT and platelet count (n = 90), platelet indices (n = 19), and platelet function/activation markers (n = 13) in patients with solid cancers (n = 61), hematological cancers (n = 17), or mixed cancer types (n = 22). Eighty-one studies had venous thrombosis as their outcome measure, while 4 had arterial thrombosis and 15 studies had both. We found significantly elevated odds ratio of 1.50 (95% confidence interval: 1.19-1.88) for thrombosis with higher platelet counts. We saw a tendency toward an association between markers of platelet activation in forms of mean platelet volume and soluble P selectin and both arterial and venous thrombosis. Only one study investigated dynamic platelet function using flow cytometry. In conclusion, platelet count is associated with CAT across different cancer types and settings. Platelet function or activation marker analysis may be valuable in assisting thrombosis risk assessment in cancer patients but is sparsely investigated so far.

Ischemic Stroke in Cancer: Mechanisms, Biomarkers, and Implications for Treatment

Ischemic stroke is an important cause of morbidity and mortality in cancer patients. The underlying mechanisms linking cancer and stroke are not completely understood. Long-standing and more recent evidence suggests that cancer-associated prothrombotic states, along with treatment-related vascular toxicity, such as with chemotherapy and immunotherapy, contribute to an increased risk of ischemic stroke in cancer patients. Novel biomarkers, including coagulation, platelet and endothelial markers, cell-free DNA, and extracellular vesicles are being investigated for their potential to improve risk stratification and patient selection for clinical trials and to help guide personalized antithrombotic strategies. Treatment of cancer-related stroke poses unique challenges, including the need to balance the risk of recurrent stroke and other thromboembolic events with that of bleeding associated with antithrombotic therapy. In addition, how and when to restart cancer treatment after stroke remains unclear. In this review, we summarize current knowledge on the mechanisms underlying ischemic stroke in cancer, propose an etiological classification system unique to cancer-related stroke to help guide patient characterization, provide an overview of promising biomarkers and their clinical utility, and discuss the current state of evidence-based management strategies for cancer-related stroke. Ultimately, a personalized approach to stroke prevention and treatment is required in cancer patients, considering both the underlying cancer biology and the individual patient's risk profile.

ABO Blood Group and the Risk of Thrombosis in Cancer Patients: A Mini-Review

Cancer-associated thrombosis (CT), especially venous thromboembolism (VTE), is a common occurrence with several factors contributing to a wide diversity in thrombosis risk. The association between ABO blood groups and the risk for CT has been examined in various studies, with non-O blood type associated with an increased thrombosis risk; however, these studies have reported varying results with recognized limitations. ABO blood groups are known to be implicated in hemostasis, in an association mediated through von Willebrand factor (VWF). In this narrative review, we aim to summarize the current knowledge surrounding the role of ABO blood groups in VTE, with a particular focus on the role of VWF and other contributing risk factors on VTE occurrence. We found evidence from literature for the impact of ABO blood groups in determining the risk of VTE in healthy populations, with a limited number of studies examining this effect in cancer patients. Additionally, research on the impact of ABO on different cancer types lacks rigor, particularly in regard to other risk factors. Overall, most studies showed strong association of increased risk of VTE amongst cancer patients with non-O blood groups and increased VWF levels. This association was weaker in a few studies. Further research is needed before a solid conclusion can be made about the ABO or ABO-VWF-mediated hypercoagulability and VTE risk in various cancers. These studies will help determine if ABO typing can be an added biomarker to improve VTE risk assessment models in cancer patients.

Cancer and arterial thrombosis: therapeutic options

A State of the Art lecture titled "Cancer and Arterial Thrombosis: Therapeutic Options" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. This State of the Art review delves into the complex relationship between cancer and arterial thromboembolism (ATE), encompassing acute coronary syndrome, ischemic strokes, and peripheral arterial disease. The burden of cancer-associated ATE is not well defined, but studies indicate elevated risks, particularly in the 6 months after a cancer diagnosis. Incidence varies among cancer subtypes, with lung cancer displaying the highest rates. Additionally, the pathophysiology of cancer-associated ATE involves a multifaceted interplay of cancer-induced hypercoagulopathy, cancer therapy-related thrombosis, and personal risk factor contributors. ATEs are clinically heterogeneous and in the context of cancer have particular mechanistic differences compared with ATE patients without cancer. This requires modifications in approach and tailored management considerations. Specific etiologies contributing to ATE, such as coronary vasospasm and non-bacterial-thrombotic endocarditis, need to be considered. The diagnosis of cancer alone usually does not contraindicate patients to standard guideline-based therapies for the management of ATE, although nuances in treatment may need to be considered in light of the underlying cancer. Atrial fibrillation in cancer patients further complicates the thrombotic landscape. Cancer patients with atrial fibrillation are at a higher risk of ATE, necessitating careful consideration of anticoagulation therapy as clinical benefits and bleeding risks need to be weighed. ATE may also be a presenting sign of underlying malignancy, which requires increased awareness and focused clinical evaluation for cancer in selected cases. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.

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

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

Management of chemotherapy-induced thrombocytopenia: guidance from the ISTH Subcommittee on Hemostasis and Malignancy

Thrombocytopenia is a common adverse effect of chemotherapy. The development of chemotherapy-induced thrombocytopenia (CIT) is influenced by cancer type and therapy, occurring in approximately one-third of patients with a solid tumor diagnosis and half of all patients with a hematologic malignancy. CIT may complicate the administration of chemotherapy, leading to therapeutic delays or dose reductions. This guidance document, presented by the International Society on Thrombosis and Haemostasis (ISTH) Subcommittee on Hemostasis and Malignancy, provides a comprehensive summary of the evidence and offers direction on the use of thrombopoietin receptor agonists (TPO-RAs) in various settings of CIT, including solid tumors, acute myeloid leukemia, stem cell transplant, and lymphoma. Studies have shown that TPO-RAs can improve platelet counts in CIT, but the clinical benefits of TPO-RA in terms of reducing bleeding, limiting platelet transfusion, avoiding chemotherapy delay, or dose reduction are uncertain. Further research is needed to optimize the selection of appropriate indications and study design to manage thrombocytopenia following chemotherapy.

Protection against cancer therapy-induced cardiovascular injury by planed-derived polyphenols and nanomaterials

Cancer therapy-induced heart injury is a significant concern for cancer patients undergoing chemotherapy, radiotherapy, immunotherapy, and also targeted molecular therapy. The use of these treatments can lead to oxidative stress and cardiomyocyte damage in the heart, which can result in heart failure and other cardiac complications. Experimental studies have revealed that chemotherapy drugs such as doxorubicin and cyclophosphamide can cause severe side effects such as cardiac fibrosis, electrophysiological remodeling, chronic oxidative stress and inflammation, etc., which may increase risk of cardiac disorders and attacks for patients that underwent chemotherapy. Similar consequences may also be observed for patients that undergo radiotherapy for left breast or lung malignancies. Polyphenols, a group of natural compounds with antioxidant and anti-inflammatory properties, have shown the potential in protecting against cancer therapy-induced heart injury. These compounds have been found to reduce oxidative stress, necrosis and apoptosis in the heart, thereby preserving cardiac function. In recent years, nanoparticles loaded with polyphenols have also provided for the delivery of these compounds and increasing their efficacy in different organs. These nanoparticles can improve the bioavailability and efficacy of polyphenols while minimizing their toxicity. This review article summarizes the current understanding of the protective effects of polyphenols and nanoparticles loaded with polyphenols against cancer therapy-induced heart injury. The article discusses the mechanisms by which polyphenols protect the heart, including antioxidant and anti-inflammation abilities. The article also highlights the potential benefits of using nanoparticles for the delivery of polyphenols.

A case of a systemic cancer-associated thrombosis successfully treated with multi-disciplinary treatment including anticoagulation therapy and anticancer drug therapy

Background

Cancer-associated thrombosis (CAT) is one of the major complications during the treatment course of cancer, which often challenges clinicians in daily clinical practice despite anticoagulation therapy.

Case summary

A 57-year-old man with a history of a liver transplantation was diagnosed with post-transplant lymphoproliferative disorders. He developed severe systemic thromboses including a massive pulmonary embolism and was treated with anticoagulation therapy including a factor Xa inhibitor. However, the systemic thromboses worsened despite the anticoagulation therapy. During the acute treatment course of the thromboses, we administered anticancer drug therapy in hopes of an improvement in the activity of the cancer status leading to a favourable effect on the thrombosis status. Multi-disciplinary treatment including anticoagulation therapy and anticancer drug therapy successfully improved the systemic thrombosis.

Discussion

Anticoagulation therapy is a standard treatment for CAT; however, some cases of CAT do not successfully improve despite anticoagulation therapy, partly due to a highly active cancer status. Anticancer drug therapy might increase the risk of a thrombosis, whereas it could improve the activity of the cancer status leading to a decreased risk of a thrombosis. A multi-disciplinary therapy might be a reasonable option especially for CAT with a highly active cancer status.

Thromboembolic events in patients who received adjuvant chemotherapy for gastric cancer: a single-center retrospective study

BACKGROUND

Thromboembolic events (TEEs) are significant adverse events that can cause serious morbidities and mortality in cancer patients receiving chemotherapy. Patients with gastric cancer (GC) treated with palliative chemotherapy have been reported to experience a TEE incidence of 5-27%. However, very few reports have addressed TEEs in adjuvant chemotherapy (AC) for GC.

METHODS

This study retrospectively analyzed 611 GC patients (stage II: 309, III: 302) who started AC with capecitabine/oxaliplatin (167 patients) or S-1 (444 patients) after undergoing curative resection between January 2013 and June 2020 at a single center. The incidence of TEEs during AC or within 1 year after AC completion was investigated, while analyzing the factors that influenced the TEEs' occurrence.

RESULTS

TEEs were confirmed in 20 patients (3.3%), and TEEs occurred in almost all patients in the S-1 group (19 patients). The most common TEE types were cerebral infarction and pulmonary thromboembolism (five patients each). Although old age (≥ 70 years, p < 0.0001), S-1 treatment (p = 0.021), and hypertension (p = 0.017) were identified as significant risk factors for TEEs in univariate analysis, only old age showed a statistically significant correlation with TEEs' occurrence in multivariate analysis (odds ratio: 3.07; 95% confidence interval 1.11-8.48; p = 0.031).

CONCLUSIONS

TEEs occurred in fewer patients with GC who had been treated with AC than patients who had received palliative chemotherapy in previous reports. However, elderly GC patients who are undergoing AC require more careful surveillance for possible TEEs, considering relatively higher incidence of them.