Hematologic Parameters during Treatment with High-Dose Medroxyprogesterone Acetate

Applications of Viscoelastic Testing in Breast Cancer Patients: A Systematic Review Focusing on Hypercoagulability and Free Flap Thrombosis

Viscoelastic testing is a clinically available method to assess hypercoagulability. This systematic review aims to provide a comprehensive overview of the existing literature and the potential use of such testing in patients with breast cancer. A systematic literature search for studies investigating the application of viscoelastic testing for patients with breast cancer was conducted. Studies were included as long as they were original, peer-reviewed, and in the English language. Studies were excluded if they were review articles, did not include breast cancer patients, or if the full text was unavailable. This review identified 10 articles that met the inclusion criteria. Two of the studies utilized rotational thromboelastometry, and an additional four studies used thromboelastography, to assess hypercoagulability in patients with breast cancer. Three of the identified articles discussed the use of thromboelastometry in free flap breast reconstruction for patients with breast cancer. One study was a retrospective chart review looking at thromboelastography and microsurgical breast reconstruction. Current literature regarding the application of viscoelastic testing in breast cancer and free flap breast reconstruction is limited, with no randomized trials thus far. However, some studies suggest that there may be potential utility in viscoelastic testing to assess risk for thromboembolism in breast cancer patients, and future research in this area is warranted.

Evaluation of the Effect of Medroxyprogesterone Acetate on Bone Marrow Progenitor Cells

Various clinical studies have demonstrated that high-dose medroxyprogesterone acetate (HD-MPA) can reduce hematologic toxicity in patients receiving chemotherapy for advanced solid tumors. The underlying mechanism(s) of this action is still unknown. A direct effect of MPA on hemopoietic cells has been postulated, but in vitro studies have given contradictory results. To clarify the biologic activity of MPA on hemopoiesis we have evaluated in vitro growth of pluripotent and committed progenitor cells from bone marrow cells which were preincubated in vitro with various doses of MPA and subsequently treated with or without the S-phase-specific drug arabinoside-cytosine (Ara-C). Four healthy subjects and 8 patients with advanced stage solid tumors with no bone marrow involvement were studied. In our experimental model we did not observe any effect of MPA on Ara-C killing of progenitor cells from either bone marrow mononuclear cells or bone marrow mononuclear cells depleted of T-lymphocytes and adherent cells. These results suggest that MPA does not act directly (or indirectly through the production of cytokines by T-lymphocytes and/or monocytes and macrophages) on bone marrow progenitors. In addition, the supposed mechanism of rendering stem cells less susceptible to the insult of cytotoxic drugs by lowering the number of progenitors in the S-phase has been ruled out by cell kinetic studies.

Fulvestrant: A Further Treatment Option for Patients with Metastatic Uterine Cancer?

BACKGROUND

Metastatic uterine cancer is notoriously difficult to treat, presenting a poor prognosis and a median survival time of less than 1 year. We present the successful use of the antiestrogen fulvestrant in an endocrine therapy-naive patient with advanced uterine cancer.

CASE REPORT

A 64-year-old female presented with advanced uterine cancer 7.0 x 6.0 x 5.5 cm in size, with infiltration of the bladder. Previous chemotherapy and radiotherapy had been unsuccessful in preventing disease progression, and the patient developed hepatic metastases. As the tumor expressed a high level of estrogen receptor, treatment with fulvestrant 250 mg/month was initiated.

RESULTS

25 months after commencing fulvestrant treatment, the tumor had decreased in size to 4.8 x 3.5 x 3.2 cm, and the hepatic metastases were no longer detectable. Throughout treatment, the patient maintained a Karnofsky performance index of 90%.

CONCLUSION

We suggest that fulvestrant may be an active and well-tolerated treatment option for patients with estrogen receptor- positive advanced uterine cancer.

Effects of medroxyprogesterone acetate therapy on advanced or recurrent breast cancer and its influences on blood coagulation and the fibrinolytic system

The effects of medroxyprogesterone acetate (MPA) therapy on advanced or recurrent breast cancer and its influence on blood coagulation and the fibrinolytic system were compared among three different therapy regimens consisting of cyclophosphamide, adriamycin, and 5-fluorouracil (CAF) + MPA and CAF or MPA alone. A clinical response was observed in 42.9% (9/21) of the patients for CAF + MPA, 36.4% (8/22) for CAF and 23.8% (5/21) for MPA alone. No marked thrombosis or its prodromal condition was observed in any group. The effects on the test values for blood coagulation and the fibrinolytic system did not significantly change in the CAF group. However, both AT-III and protein C significantly increased above the normal ranges in the CAF+MPA and MPA groups. Increases in factor X, plasminogen, and alpha 2-plasmin inhibitor/plasmin complex (PIC) and decreases in fibrinogen, tissue plasminogen activator, and D-dimer, were all observed in the MPA and CAF + MPA groups, especially in the MPA group, although these changes remained within the normal ranges. The data indicated that MPA has various influences on blood coagulation and the fibrinolytic system, but these changes did not suggest activation of the blood coagulation system.

Changes in hematologic parameters during treatment with medroxyprogesterone acetate for breast cancer

To elucidate the etiology of the thrombogenic effects of high-dose medroxyprogesterone acetate (MPA) in the treatment of breast cancer, hematologic parameters were sequentially assessed in 12 patients receiving MPA 800 mg p.o. daily for 6 months as adjuvant hormone therapy after mastectomy. The results were as follows. (1) Coagulation system: levels of factor VII and fibrinogen decreased significantly, whereas factors II and IX increased significantly, with a shortened activated partial thromboplastin time. (2) Fibrinolytic system: plasminogen and alpha 2-plasmin inhibitor-plasmin complex increased, whereas fibrinogen degradation products remained low. (3) Anticoagulation system: antithrombin III increased significantly. (4) These changes were most marked after 2 or 4 weeks of MPA treatment, and returned to the pretreatment level one month after discontinuation of treatment. (5) No patients in this study developed thromboembolic disease during or after MPA administration. These results indicate that MPA may induce a hypercoagulable state, but this state does not directly lead to the development of thrombosis.

Hypercoagulable state induced by cytostatic drugs in stage II breast cancer patients

An increased incidence of thromboembolic complications occurring in cancer patients during chemotherapy was recently reported. In view of this report, a study in 49 patients receiving adjuvant chemotherapy for Stage II breast cancer was begun in order to determine the effect of antineoplastic drugs on coagulation factors and platelet function. Among the coagulation factors, a significant decrease of thrombin time and partial prothrombin time was observed, whereas platelet function tests were unchanged. This finding suggests a trend towards hypercoagulability induced by chemotherapy. This effect should be considered when chemotherapy is employed in advanced cancer patients at high risk for thrombosis.