Cancer-associated thrombosis: the when, how and why

Anticoagulant effects of edoxaban in cancer and noncancer patients with venous thromboembolism

BACKGROUND

Edoxaban, a direct oral anticoagulant (DOAC), is a first-line treatment for venous thromboembolism (VTE) and the suppression of VTE recurrence. In patients with cancer, however, recurrent VTE after DOAC treatment may be more common than in noncancer patients. To evaluate our hypothesis that the anticoagulation effect of edoxaban is lower in VTE patients with cancer than in noncancer patients.

METHODS

This study was a prospective, multicenter, observational study including patients treated with edoxaban for VTE in Japan. The primary outcome was the difference in the prothrombin time (PT), activated partial thromboplastin time (APTT), and D-dimer level at 5 h after initial edoxaban administration between the cancer and noncancer groups. An additional outcome was the longitudinal change in PT and APTT from 5 h to overnight after edoxaban administration. The incidence of adverse events was further investigated.

RESULTS

PT and APTT at 5 h after initial edoxaban administration were not significantly different between the cancer (n = 84) and noncancer groups (n = 138) (e.g., log-transformed APTT 3.55 vs. 3.55, p = 0.45). However, D-dimer in the cancer groups was significantly greater than that in the noncancer groups (log-transformed 1.83 vs. 1.79, p = 0.009). PT and APTT significantly decreased from 5 h to overnight after edoxaban, but a similar pattern was observed in each group. All adverse events after edoxaban administration were also similar between patients with cancer and noncancer.

CONCLUSION

PT and APTT after edoxaban administration were similar between VTE patients with cancer and noncancer groups, suggesting that edoxaban has anticoagulation effects on cancer-associated VTE similar to those of noncancer patients.

TRIAL REGISTRATION

UMIN000041973; Registration Date: 2020.10.5.

Cancer genetic profile and risk of thrombosis

Cancer-associated thrombosis (CAT) remains a leading cause of morbidity and mortality among oncology patients, with an incidence influenced by tumor type, stage, treatment, and molecular characteristics. This review explores the molecular determinants of venous thromboembolism (VTE) in cancer, emphasizing its pathophysiology and association with specific oncogenic alterations. Certain molecular profiles exhibit heightened VTE risk. In lung cancer, due to hypercoagulability mechanisms linked to tissue factor overexpression, an increased incidence of VTE has been reported in populations with ALK (30-40 %) and ROS1 rearrangements (34.7-46.6 %). In gastrointestinal cancers, while pancreatic adenocarcinoma has the highest VTE rates (up to 22 %), KRAS mutations seem to be implicated but not conclusively validated. Similarly, colorectal cancer mutations (KRAS/BRAFV600E) and antiangiogenic therapies may elevate thrombotic risk, warranting further study. High-grade gliomas, particularly glioblastomas, present VTE rates up to 30 %, driven by podoplanin-induced platelet aggregation. IDH1 mutations inversely correlate with thrombosis, highlighting its protective role. Emerging evidence suggests that agnostic biomarkers such as STK11 mutations influence VTE risk across tumor types, while others like KRAS, MET and BRCA mutations show inconclusive results. Large-scale validation studies are imperative to integrate molecular profiles into clinical practice. Until then, management decisions should be individualized, balancing the thrombotic risks with oncologic considerations.

Venous and arterial thrombosis in patients receiving immune checkpoint inhibitors

BACKGROUND

Immune checkpoint inhibitors (ICPi) have been associated with a prothrombotic and pro-atherogenic tendency which could lead to an increased risk of thrombosis. The aim of this study was to investigate the incidence of venous and arterial thrombosis (myocardial infarction or ischemic stroke) in patients who used ICPi as compared with the general population. Furthermore, we investigated the association between the occurrence of venous or arterial thrombosis and mortality.

METHODS

Patients receiving immune checkpoint inhibitors ICPi between January 1, 2013, and May 31, 2020, at the University Medical Center Utrecht, the Netherlands, were included in this study. Indirect standardization was used to compare the incidence rates of venous and arterial thrombosis in patients who used ICPi to the age- and sex weighted incidence rates in the general population. Time-dependent Cox proportional hazard regression model was used to calculate Hazard ratios (HRs) with 95% CIs to investigate the association between the occurrence of a venous or arterial event after start of an ICPi and mortality.

RESULTS

The age- and sex weighted incidence rates in 663 patients who used ICPi as compared to the general population was 22.7-fold (95% CI 16.6-31.0) increased for venous thrombosis, 3.0-fold (95% CI 1.2-7.1) increased for myocardial infarction, and 3.2-fold (95% CI 1.6-5.7) increased for ischemic stroke. After adjustment, the all-cause mortality risk was 2.3-fold (95% CI 1.5-3.5) increased for patients who were diagnosed with venous thrombosis during follow-up and 2.2-fold (95% CI 1.1-4.1) increased for patients who were diagnosed with arterial thrombosis during follow-up as compared with patients without venous or arterial thrombosis during follow-up.

CONCLUSION

Patients receiving ICPi have elevated risks of venous thrombosis and arterial thrombosis. Occurrence of venous thrombosis or arterial thrombosis during treatment with ICPi is associated with an increased mortality risk.

The incidence of venous thromboembolism by type of solid cancer worldwide: A systematic review

There is a well-established relationship between cancer and venous thromboembolism (VTE). Thrombosis in cancer is of major concern as it is a leading cause of mortality, impairs quality of life, and can adversely impact treatment protocols. Despite the role of thrombosis in cancer, no singular source consolidates data on VTE incidence by cancer type worldwide. This systematic review aims to report the incidence of VTE by type of solid cancer worldwide. The current analysis used three databases (MEDLINE, Embase, Cochrane Library) to identify relevant articles. All articles were written in English, assessed solid cancers in adults (≥18; males, females), and reported the incidence of VTE, or information that could be used to calculate incidence. After completing the search and removing duplicates, 3077 articles were assessed. All articles were screened by title and abstract, followed by a full-text review. A total of 124 articles were included in the final evaluation. The cumulative reported incidence of VTE across all types of solid cancer was 9.74 %. The highest reported incidence of VTE was in gastroesophageal cancer (15.43 %), whereas the lowest incidence was in prostate cancer (1.58 %). The two most reported cancers by country within our study cohort were colorectal (n = 23) and lung cancer (n = 23). The reported incidence of VTE in colorectal cancer was highest in Mexico (22.10 %), and lung cancer was highest in Canada (32.91 %). In conclusion, gathering data on global VTE rates in solid cancer identified high-risk cancers and highlighted under-investigated areas that require attention to reduce VTE occurrence in cancer patients.

In Vivo pharmacokinetic interactions of ribociclib with rivaroxaban and apixaban in rats: implications for increased drug exposure and dose adjustments

Background

Apixaban (API) and rivaroxaban (RIVA) are orally available inhibitors of coagulation factor Xa and are commonly used to treat cancer-related venous thrombosis. Ribociclib (RIBO), a first-line treatment for hormone receptor-positive/human epidermal growth factor receptor 2 negative (HR+/HER2-) advanced breast cancer, is an inhibitor of CYP3A4, P-gp, and BCRP. Given the potential for these drugs to be co-administered in clinical settings, there is limited information regarding the pharmacokinetic drug-drug interactions (DDIs) between ribociclib and these anticoagulants. This study aimed to evaluate the extent of DDIs between ribociclib and rivaroxaban or apixaban in rats and to explore the optimization of drug dosing strategies.

Methods

Male Sprague-Dawley rats were divided into 9 groups (n = 6), receiving ribociclib, apixaban, rivaroxaban, ribociclib with rivaroxaban, ribociclib with apixaban, and combinations with reduced doses and time intervals. Blood concentrations were measured using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). Pharmacokinetic parameters such as AUC, Cmax, CLz/F, and Vz/F.

Results

Ribociclib significantly increased exposure to both rivaroxaban and apixaban, with a greater impact on rivaroxaban. Specifically, ribociclib increased the AUC0-t, AUC0-∞ and Cmax of rivaroxaban (normal dose) by about 2.4-fold, 2.1-fold and 1.8-fold, while increasing apixaban exposure by about 60.82%, with a trend towards an increase in Cmax that was not statistically significant. When co-administered with ribociclib, even at a reduced dosage of 1 mg/kg, rivaroxaban exhibited a significant increase in exposure, with the AUC increasing by 2.3-fold and Cmax by 1.3-fold. Despite the reduction in dosage, the pharmacokinetic effect of ribociclib on rivaroxaban persisted. While administration of rivaroxaban 12 h after ribociclib resulted in a less pronounced increase in exposure compared to the normal-dose group. The results of qRT-PCR showed that ribociclib reduced the expression of Cyp3a1 and Abcg2 in rat intestine.

Discussion

This research highlights the need for careful consideration of dosing regimens to minimize toxicity risk and optimize the safety of clinical co-administration of ribociclib with rivaroxaban.

Myocardial infarction and pulmonary embolism in pancreatic cancer: a case report of two manifestations of Trousseau's syndrome

Introduction

The simultaneous occurrence of acute myocardial infarction (AMI) and venous thromboembolism (VTE) is rare and often associated with underlying malignancies. This study reports a rare case of concurrent AMI and pulmonary thromboembolism in a patient diagnosed with pancreatic cancer.

Case presentation

A 70-year-old woman presented with acute chest pain and ST-segment elevation myocardial infarction, prompting immediate percutaneous coronary intervention (PCI) with the deployment of a drug-eluting stent. Following PCI, she was treated with optimal medical therapy, including dual antiplatelet therapy. Subsequent investigations revealed pulmonary embolism, deep vein thrombosis, and imaging findings suggestive of pancreatic cancer. Anticoagulation therapy was initiated to manage the VTE. Approximately 1 month after PCI, antithrombotic agents were temporarily discontinued for pancreatic mass biopsy, confirming pancreatic ductal adenocarcinoma. The patient was referred for palliative chemotherapy.

Discussion

This case highlights the clinical manifestation of Trousseau's syndrome, characterized by cancer-associated thromboembolism, and underscores the importance of coordinated antithrombotic management in complex clinical settings.

Risk factors for in-hospital venous thromboembolism in patients with bladder cancer: A retrospective single-center study

OBJECTIVE

In this study, we retrospectively analyzed the incidence of and risk factors for in-hospital venous thromboembolism (VTE) in patients with bladder cancer and explored measures to reduce the incidence of and/or prevent in-hospital VTE and mortality.

METHODS

The clinical data of 5744 patients with bladder cancer who were admitted to the Second Hospital of Tianjin Medical University during a 5-year period were summarized and then analyzed to determine the risk factors for in-hospital VTE in patients with bladder cancer with the aim of identifying preventive measures.

RESULTS

Univariate analysis revealed significant differences between the VTE group and the non-VTE group in terms of age, sex, Caprini score, surgical treatment status, tumor stage, D-dimer level, PT, APTT, and Hb (P < 0.05). Multiple factor analysis further confirmed that the Caprini score, surgical treatment status, D-dimer level, PT, and APTT were independent risk factors for VTE.

CONCLUSION

Analyses revealed that a high Caprini score, surgical treatment, an elevated D-dimer level, a short PT, and a short APTT were independent risk factors for in-hospital VTE in patients with bladder cancer and that active preventive measures should be implemented to reduce the incidence of in-hospital VTE as well as mortality.

Hypercoagulation after neoadjuvant immunochemotherapy as a new prognostic indicator in patients with locally advanced gastric cancer undergoing surgery

BACKGROUND

Coagulation status is closely related to the progression of malignant tumors. In the era of neoadjuvant immunochemotherapy (NICT), the prognostic utility of coagulation indicators in patients with locally advanced gastric cancer (LAGC) undergoing new treatments remains to be determined.

AIM

To determine whether hypercoagulation is an effective prognostic indicator in patients with LAGC who underwent radical resection after NICT.

METHODS

A retrospective analysis of clinical data from 104 patients with LAGC, who underwent radical resection after NICT between 2020 and 2023, was performed. D-dimer and fibrinogen concentrations were measured one week before NICT, and again one week before surgery, to analyze the association between these two indicators and their combined indices [non-hypercoagulation (D-dimer and fibrinogen concentrations within the upper limit of normal) vs hypercoagulation (D-dimer or fibrinogen concentrations above the upper limit of normal)] with prognosis. After radical resection, patients were followed-up periodically. The median follow-up duration was 21 months.

RESULTS

Data collected after NICT revealed that the three-year overall survival (OS) and disease-free survival (DFS) rates the non-hypercoagulation group were significantly better than those in the hypercoagulation group [94.4% vs 78.0% (P = 0.019) and 87.0% vs 68.0% (P = 0.027), respectively]. Multivariate analysis indicated that hypercoagulation after NICT was an independent factor for poor postoperative OS [hazard ratio (HR) 4.436, P = 0.023] and DFS (HR 2.551, P = 0.039). Pre-NICT data demonstrated no statistically significant difference in three-year OS between the non-hypercoagulation and hypercoagulation groups (88.3% vs 84.1%, respectively; P = 0.443).

CONCLUSION

Hypercoagulation after NICT is an effective prognostic indicator in patients with LAGC undergoing radical gastrectomy.

The role of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as venous thromboembolism predictors in breast cancer patients pre- and post-therapy

OBJECTIVES

Breast cancer (BC) accounts for 12.3% of all cancer-associated venous thromboembolism (VTE). Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are recognized inflammatory biomarkers but have not been incorporated into thrombosis risk stratification models. We evaluated NLR and PLR as predictive biomarkers for VTE in BC patients to determine their optimal predictive cutoffs and net predictive value before and after treatment.

METHODS

We conducted a prospective pilot study that involved 56 women with BC, recruited prior to treatment (chemotherapy and immunotherapy) initiation with at least 6-month monitoring for VTE. NLR and PLR were assessed pre and posttreatment.

RESULTS

Five patients (8.9%) developed VTE. NLR and PLR increased significantly posttreatment (P = 0.001). Post, not pretreatment, NLR (P = 0.029) and PLR (P = 0.033) were significantly associated with VTE occurrence. Receiver Operating curve analysis indicated enhanced predictive capacity for VTE postimmunotherapy. Optimal posttreatment cutoffs were 3.6 for NLR and 280 for PLR, aligning with existing literature, with slightly elevated NLR.

CONCLUSIONS

Posttreatment NLR and PLR have higher predictability for VTE in patients receiving immunotherapy compared to chemotherapy. NLR outperforms PLR, particularly postimmunotherapy. This data holds promise for thrombosis risk stratification in the context of immunotherapy but requires evaluation in larger studies.

Ischaemic and bleeding risk after ST-elevation myocardial infarction in patients with active cancer: a nationwide study

Aims

Treatment of patients with cancer presenting with ST-elevation myocardial infarction (STEMI) is complex given the increased risk of both thrombotic and major bleeding complications.

Methods and results

A nationally linked cohort of STEMI patients between January 2005 and March 2019 was obtained from the UK Myocardial Infarction National Audit Project and the UK National Hospital Episode Statistics Admitted Patient Care registries. The primary outcomes were major bleeding and re-infarction at 1 year following admission with STEMI. Major bleeding was defined as bleeding events that require hospital admission. Re-infarction was defined as acute MI according to the fourth Universal Definition of Myocardial Infarction. A total of 322 776 STEMI-indexed admissions were identified between January 2005 and March 2019. Of those, 7050 (2.2%) patients were diagnosed with active cancer. Cancer patients were older with more cardiovascular comorbidities. Cancer patients received invasive coronary angiography (62.2% vs. 72.7%, P < 0.001) and percutaneous coronary intervention (58.4% vs. 69.5%, P < 0.001) less often compared with patients without cancer and were less likely to be prescribed dual antiplatelet therapy (85% vs. 95.4%, P < 0.001). The incidence of major bleeding (6.5% vs. 3.5%, P < 0.001) and re-infarction (cancer 5.7%, no cancer 5.1%, P = 0.01) was higher in cancer patients at 1 year. After adjustment for differences in baseline covariates, a similar risk of re-infarction (sub-hazard ratios (SHR) 1.10, 95% CI 0.94-1.27) and a 50% increased risk of major bleeding (SHR 1.49, 95% CI 1.30-1.71) were observed in cancer patients.

Conclusion

Compared with non-cancer patients, cancer patients have a higher risk of major bleeding but not of re-infarction. Mitigating bleeding risk in STEMI patients with cancer is of paramount importance to improve outcomes.

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.

Computed tomographic pulmonary angiography using low tube voltage and slow contrast medium injection

PURPOSE

The diagnosis of acute pulmonary thromboembolism (PTE) is often performed by computed tomographic pulmonary angiography (CTPA). This study investigated the effects of a CTPA protocol combining slow contrast medium injection and low tube voltage on radiation exposure and image quality.

METHODS

We retrospectively analyzed 82 patients undergoing CT scans for cancer treatment efficacy or follow-up, and simultaneous PTE exclusion. Patients were divided into two groups. Those in Group A (n = 43) received slow contrast injection (0.7-1.5 mL/s), and those in Group B (n = 39) received rapid injection (2.6-4.2 mL/s). All CT scans were performed using a multi-detector row CT scanner with optimized tube voltage and current settings. Contrast medium doses were adjusted based on the patient's body weight.

RESULTS

Group A had significantly lower radiation exposure compared with Group B. PTE was diagnosed in eight patients in Group A and seven in Group B, with no significant difference in prevalence rates. While Group B indicated higher mean CT values in the CTPA phase, the difference in the mean CT value of the pulmonary artery was only 29.6 Hounsfield units. Group A demonstrated superior contrast enhancement in parenchymal organs during the second phase.

CONCLUSION

The slow-injection CTPA method proved effective for simultaneous PTE exclusion and cancer treatment evaluation, maintaining diagnostic accuracy with reduced risks associated with rapid injection.

Short- and long-term outcomes of percutaneous left atrial appendage occlusion in cancer patients

Introduction and objectives

Percutaneous left atrial appendage occlusion (LAAO) is a viable option to mitigate bleeding and stroke risks in patients with atrial fibrillation (AF) who are not eligible for oral anticoagulation. Its safety and efficacy in cancer patients remain unclear due to their exclusion from trials. This study aimed to compare short- and long-term LAAO outcomes between cancer and non-cancer patients.

Methods

Retrospective single centre study of 361 consecutive patients who underwent LAAO between april-2010 and december-2023 were included. Short-term outcomes included periprocedural complications, 30-day hospital readmission and mortality. Long-term outcomes included the composite of stroke, bleeding, and mortality and each component assessed separately.

Results

The study included 93 cancer patients (54 % active, 46 % in remission) and 268 non-cancer patients. Baseline characteristics were similar, including ischemic and bleeding risk profiles (CHA2DS2-VASc: 4.5 ± 1.4 vs. 4.4 ± 1.5; HAS-BLED: 3.3 ± 0.9 vs. 3.2 ± 0.9), previous stroke and total bleeding events. Short-term outcomes showed no significant differences in periprocedural complications (7 % vs. 6 %), 30-day readmission (2 % vs. 3 %), or 30-day mortality (0 % vs. 1.5 %). Over 32 months, there was no significant difference regarding the composite endpoint (p = 0.067), stroke (SHR 0.54; p = 0.25) or bleeding events (SHR 1.36; p = 0.35). LAAO was effective in terms of stroke reduction in cancer and non-cancer patients (p = 0.027 and p = 0.006, respectively). All-cause mortality rates were higher in cancer patients (p = 0.002), mainly due to cancer progression and infections.

Conclusions

LAAO procedure was safe and effective in both populations. Cancer patients experienced higher rates of all-cause mortality, with no differences in stroke and bleeding outcomes between groups.

Evaluation of treatment for diffuse large B-cell lymphoma using plasma D-dimer levels

It has been documented that D-dimer levels have potential utility as a measure of tumor activity in diffuse large B-cell lymphoma (DLBCL), however whether it can be used as a predictive marker of treatment outcome has not been established. This study means to retrospectively evaluate the role of D-dimer in prediction of treatment efficacy in patients with DLBCL. 151 patients with newly diagnosed DLBCL were enrolled. Blood samples were taken from those patients during the initial visit to our hospital and again after two cycles of chemotherapy to measure D-dimer levels. The link between plasma D-dimer concentrations and patients' clinical characteristics was explored before and after treatment. D-dimer levels within the range of 0-1 µg/mL were considered negative, while readings above this range were considered positive. D-dimer difference percentage (Ddp) represents the percentage change in D-dimer levels before and after chemotherapy, calculated as (post-chemotherapy D-dimer minus pre-chemotherapy D-dimer) / pre-chemotherapy D-dimer × 100. Patients showed statistically different plasma D-dimer levels at initial consultation across treatment-response groups: CR (0.63 µg/mL [0.43-1.27]), PR (1.39 µg/mL [0.73-2.46]), SD (0.89 µg/mL [0.59-1.24]), and PD (1.34 µg/mL [0.67-2.62]). After chemotherapy, the PR group exhibited a mean D-dimer level of -0.38 µg/mL (range - 1.64 to -0.11), which was significantly lower than that of the PD group (mean 0.04 µg/mL, range - 0.40 to 0.79; p < 0.05). The CR group revealed significantly lower initial D-dimer levels (median 0.63 µg/mL) and greater reductions after chemotherapy compared to the non-CR group (median 1.17 µg/mL, p < 0.05). Patients with coagulation disorders such as DIC, DVT, or PE were excluded to minimize confounding factors. While this study demonstrates the utility of D-dimer in predicting short-term treatment response, the relationship with long-term outcomes such as PFS and OS requires further investigation. Patients who respond well to chemotherapy typically exhibit lower D-dimer levels at the initial diagnosis. Those in the SD or PD groups usually experience a greater increase in D-dimer levels following chemotherapy. Consequently, variations in plasma D-dimer levels before and after treatment may offer valuable insights for evaluating the efficacy of chemotherapy treatment.

Dual-positive gastric cancer: an extremely malignant subtype of gastric cancer with high serum alpha-fetoprotein and carcinoembryonic antigen concentrations

Background

Alpha-fetoprotein-producing gastric cancer (AFPGC) is a highly malignant subtype of gastric cancer, but solely alpha-fetoprotein may fail to accurately predict the prognosis. Although the utilization of multi tumor markers could improve stratified patient management, such research in AFPGC is still blank. This study seeks to evaluate whether combining multiple tumor markers can enhance risk stratification and identify AFPGC subtypes with poor prognosis.

Methods

We first screened for patients with elevated serum CEA levels within the AFPGC cohort and evaluated their prognosis. Tumor characteristics and overall health conditions were analyzed to identify factors contributing to CEA elevation. Finally, the treatment responses of this group to different treatment modalities were also reviewed.

Results

Approximately 45% of gastric cancer patients with elevated serum AFP also show increased CEA levels, classifying them as the dual-positive gastric cancer (DPGC) subgroup. These patients exhibit significantly shorter overall survival, heightened metastasis risk, and are more susceptible to systemic inflammation, immune response dysregulation, malnutrition, and cancer-related thrombosis. The elevation in serum CEA levels may indicate gastric cancer liver metastasis and increased neutrophils. While surgery is optimal for AFPGC, DPGC patients benefit significantly from immunotherapy combined with chemotherapy.

Conclusions

In AFPGC, combining serum AFP and CEA offers a more accurate prognosis. The poor prognosis in DPGC may be associated with aggressive local properties and systemic complications. Liver metastases and increased neutrophils are associated with increased serum CEA in AFPGC. Immunochemotherapy is a viable option for DPGC patients who cannot undergo surgery.

Magnitude of cancer-associated thrombosis in Africa: A systematic review and meta-analysis

Comprehensive data on the epidemiology of cancer-related thrombosis in Africa has been sparse until recently. Thus, this review was aimed to investigate the magnitude of cancer-related thrombosis in Africa. To obtain key articles, comprehensive search was conducted using various databases. A random-effects model was used to determine the pooled magnitude. Heterogeneity across the studies was checked, and publication bias was determined. The pooled magnitude of thrombosis among cancer patients in Africa is 11.65% (95% confidence interval [CI]: 9.02-14.28). Advanced age, comorbidity, and level of D-dimer were the factors associated with cancer-associated thrombosis. Cancer-related thrombosis has become a significant public health burden in Africa. About 3 out of 25 cancer patients are at increased risk of acquiring thrombosis. It is better to provide training and capacity-building programs for healthcare providers in Africa on the prevention, diagnosis, and management of cancer-related thrombosis and develop standardized evidence-based multidisciplinary approach care guidelines.

Endothelial Dysfunction Markers in Ovarian Cancer: VTE Risk and Tumour Prognostic Outcomes

Ovarian cancer (OC) presents daunting lethality rates worldwide, with frequent late-stage diagnosis and chemoresistance, highlighting the need for improved prognostic approaches. Venous thromboembolism (VTE), a major cancer mortality factor, is partially driven by endothelial dysfunction (ED). ED's pro-inflammatory state fosters tumour progression, suggesting a VTE-independent link between ED and cancer. Given this triad's interplay, ED markers may influence OC behaviour and patients' prognosis. Thus, the impact of ED-related genes and single-nucleotide polymorphisms (SNPs) on OC-related VTE and patient thrombogenesis-independent prognosis was investigated. NOS3 upregulation was linked to lower VTE incidence (χ2, p = 0.013), while SELP upregulation was associated with shorter overall survival (log-rank test, p = 0.048). Dismissing patients with VTE before OC diagnosis, SELP rs6136 T allele carriers presented lower progression-free survival (log-rank test, p = 0.038). Nevertheless, due to the SNP minor allele underrepresentation, further investigation is required. Taken together, ED markers seem to exhibit roles that depend on the clinical context, such as tumour-related thrombogenesis or cancer prognosis. Validation with larger cohorts and more in-depth functional studies are needed for data clarification and potential therapeutic strategies exploitation to tackle cancer progression and thrombosis in OC patients.

Incidence and risk factors of VTE in lung cancer: a meta-analysis

BACKGROUND

Lung cancer has maintained a high prevalence and mortality. Besides, venous thromboembolism (VTE) is the third most common disease of cardiovascular disease. Lung cancer with VTE usually influenced the overall survival in the follow-up. In the development of lung cancer, vigilance against and early diagnosis of VTE is of significance.

METHODS

We searched the databases of PubMed, Web of Science, Embase and Cochrane for related research up to 30 November 2023 and extracted information of incidence, odds ratio (OR), hazard ratio (HR) and their 95% confidence intervals (CIs), for evaluating the incidence of VTE and its risk factors.

RESULTS

A total of 54 articles and 873,292 records were included in our study. The pooled incidences of VTE and PE were 6% and 3%, respectively. Subgroup analysis revealed that the tumour, node and metastasis (TNM) stage (HR= 5.43, 95% CI: 2.42, 12.22), metastasis (HR= 2.67, 95% CI: 1.35, 5.29) and chemotherapy (HR= 2.27, 95% CI: 1.11, 4.65) had major influence on VTE occurrence.

CONCLUSIONS

Lung cancer complicated with VTE is unignorable, and its occurrence varies widely by tumour staging, tissue type and treatment. The results may aid in clinical decision-making about lung cancer in higher risk with VTE and weather receiving anticoagulant prophylaxis.

Predicting survival benefits of immune checkpoint inhibitor therapy in lung cancer patients: a machine learning approach using real-world data

BACKGROUND

Due to the heterogeneity in the effectiveness of immunotherapy for lung cancer, identifying predictors is crucial.

AIM

This study aimed to develop a machine learning model to identify predictors of overall survival in lung cancer patients treated with immune checkpoint inhibitors (ICIs).

METHOD

A retrospective analysis was performed on data from 1314 lung cancer patients at the Chongqing University Cancer Hospital from September 2018 to September 2022. We used the random survival forest (RSF) model to identify survival-influencing factors, using backward elimination for variable selection. A Cox proportional hazards (CPH) model was constructed using the most significant predictors. We assessed model performance and generalizability using time-dependent receiver operating characteristics (ROC) and predictive error curves.

RESULTS

The RSF model demonstrated better predictive accuracy than the CPH (IBS 0.17 vs. 0.17; C-index 0.91 vs. 0.68), with better discrimination and prediction performance. The influential variables identified included D-dimer, Karnofsky performance status, albumin, surgery, TNM stage, platelet count, and age. The RSF model, which incorporated these variables, achieved area under the curve (AUC) scores of 0.95, 0.94, and 0.98 for 1-, 3-, and 5-year survival predictions, respectively, in the training set. The validation set showed AUCs of 0.94, 0.90, and 0.95, respectively, exceeding the performance of the CPH model.

CONCLUSION

The study successfully developed a machine learning model that accurately predicted the survival benefits of ICI therapy in lung cancer patients, supporting clinical decision-making in lung cancer treatment.

D-dimer as a Predictive Biomarker of Response to Chemotherapy in Patients With Metastatic Breast Cancer

Background

Tumor-induced coagulation is widely observed in cancer patients. Moreover, it is associated with tumorigenesis, tumor progression and metastasis, by creating a proliferative and proangiogenic microenvironment. Therefore, D-dimer, a fibrin degradation product, correlates with tumor prognosis in several cancer types.

Objectives

This study aims to investigate whether D-dimer levels can be a predictive and monitoring indicator for chemotherapy response in metastatic breast cancer (MBC) patients.

Design

This was a prospective study.

Methods

This study included two groups, 76 patients diagnosed with metastatic breast carcinoma and 25 patients with primary breast carcinoma. Plasma D-dimer levels were measured prospectively before chemotherapy initiation, and after the fourth treatment cycle in MBC patients. D-dimer levels before chemotherapy (D0) were analyzed using Receiver Operating Characteristic (ROC) curves to determine the optimal cut-off baseline values of D0, and to evaluate their discriminatory abilities in predicting response to chemotherapy.

Results

In the preliminary response evaluation, the mean level of D-dimer significantly decreased by 0.65 μg/ml in patients with partial response patterns, and by 0.5 μg/ml in patients with stable disease. In the disease progression group, a marked increase was seen in D-dimer levels by 1.2 μg/ml. Analysis of ROC curves showed that D-dimer levels at D0 could discriminate the response to chemotherapy, whereas progressive disease rate correlated with higher levels of D-dimer.

Conclusion

D-dimer level in plasma is a useful predictive and monitoring marker of response to chemotherapy in metastatic breast cancer.

Treatment with Antithrombotics in the Last Year of Life-Incidence of Bleeding and Side Effects After Deprescribing

Background: Patients in palliative care are often treated with antithrombotics, even in the late stages of disease. Clear guidelines regarding deprescribing are lacking. Objective: The aims of this study were to investigate bleeding as a side effect of antithrombotic treatments the last year in life and map the timing of deprescribing. Methods: A retrospective cohort study was performed. All medical records were screened for deceased patients admitted to a palliative care unit in Stockholm, Sweden, over a 3-year period. Patients with antithrombotics were identified; data on bleeding, and on side effects due to deprescribing, were extracted from the medical records. Log-binomial models were used to explore factors associated with bleeding. Results: Of 1501 patients, 897 were treated with antithrombotics during the last year of life (mean age 75 years, 41% women). Of these, 56% continued treatment up until the last 3 days of life. Of the 897 patients, 144 (16%) had at least one bleeding during the treatment. The risk for bleeding was significantly higher for men with prostate cancer compared to other cancer forms, adjusted relative risk 1.9 (95% CI 1.1-3.2). No difference in risk for bleeding was found between sex, age groups, type of antithrombotics, or indication. Two patients (0.2%) developed strokes after antithrombotics were deprescribed. Conclusions: Treatment with antithrombotics during the last year of life is associated with a high risk of bleeding. In this cohort, men with prostate cancer seemed to have more side effects of bleeding than other groups. Few experienced side effects from deprescribing.

Elevated Thrombin Generation and Venous Thromboembolism Incidence in Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Compared with Minimally Invasive Rectal Surgery

INTRODUCTION

 Surgical treatment of colorectal cancer carries a risk for venous thromboembolism (VTE). We investigated changes in coagulation and fibrinolysis and the VTE incidence within 30 days in patients undergoing open cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) for peritoneal metastases from colorectal cancer and minimally invasive surgery (MIS) for localized rectal cancer.

METHODS

 This cohort study included 45 CRS + HIPEC and 45 MIS patients. Blood samples were obtained preoperatively, at the end of surgery, and postoperative day (POD) 1, 3 to 4, and 5 to 7. Systematic ultrasonographic screening for VTE was performed between POD 3 and 7. Computed tomography scan was performed if complications were suspected. The primary endpoint was the difference in mean change (Δ) with [95% confidence intervals] from preoperative to end of surgery in prothrombin fragment 1 + 2 (F1 + 2) levels. Secondary endpoints were the difference in mean change in biomarkers of coagulation and fibrinolysis from preoperative to POD 5 to 7 and the VTE incidence.

RESULTS

 F1 + 2 levels increased from preoperative to the end of surgery in both groups. The mean increase from preoperative to end of surgery in F1 + 2 levels was significantly greater in CRS + HIPEC patients than MIS patients: Δ1,322 [1,040:1,604] pmol/L, p < 0.01. The VTE incidence was significantly higher after CRS + HIPEC than MIS (24 vs. 5%, p = 0.01).

CONCLUSION

 F1 + 2 levels were increased after both procedures, but to a far greater extent following CRS + HIPEC. The VTE incidence within 30 days was significantly higher in patients treated with CRS + HIPEC than in MIS patients.

External Validation of Risk Scores for Predicting Venous Thromboembolism in Ambulatory Patients with Lung Cancer

BACKGROUND

The purpose of this study was to evaluate the discriminatory capability of the Khorana, PROTECHT, CONKO, and COMPASS-CAT scores in ambulatory patients with lung cancer.

METHODS

This retrospective cohort study included 591 patients with newly diagnosed lung cancer. A symptomatic or incidental VTE occurred in 108 patients.

RESULTS

The Khorana score at a 2-point threshold had a discriminatory capability with an odds ratio (OR) of 1.80 and an AUC of 0.57 for 6 months, and an OR of 1.51 and an AUC of 0.55 for 12 months. The CONKO score at a 2-point threshold had a stronger discriminatory capability for both 6 months and 12 months with ORs of 3.00 and 2.13, and AUCs of 0.63 and 0.59, respectively. Additionally, higher white blood cell counts, higher neutrophil counts, hypoalbuminaemia, and not undergoing lung surgery were related to VTE occurrence (p < 0.05).

CONCLUSIONS

The Khorana score with the 2-point threshold was validated in ambulatory patients with lung cancer, with the results indicating a decline in its discriminatory capability over time (at 12 months vs. 6 months from diagnosis). The CONKO score at the original 2-point threshold showed a stronger discriminatory capability but further validation with a larger sample size is recommended. The identified predictors should be further investigated in future research.

D-dimer cut-off value for predicting venous thromboembolism at the initial diagnosis in Japanese patients with advanced lung cancer

OBJECTIVE

Cancer is a well-known risk factor for venous thromboembolism. The D-dimer level is used to predict venous thromboembolism; however, reports on an appropriate D-dimer cut-off value in Japanese patients with advanced lung cancer are lacking. Therefore, this study aimed to calculate the D-dimer cut-off value for venous thromboembolism at the time of lung cancer diagnosis.

METHODS

The Rising-venous thromboembolism/NEJ037 study was a multicenter, prospective observational study. Patients with lung cancer who were contraindicated for radical resection or radiation were enrolled and followed up for 2 years. In the present study (jRCT no. 061180025), a receiver operating characteristic curve for D-dimer levels was created using the dataset of the Rising-venous thromboembolism/NEJ037 study.

RESULTS

The Rising-venous thromboembolism/NEJ037 study included a total of 1008 patients, of whom 976, whose D-dimer levels had been measured at the time of cancer diagnosis, were included in the present study. At the time of lung cancer diagnosis, 62 (6.3%) and 914 (93.7%) patients presented with and without venous thromboembolism, respectively. The D-dimer values ranged from 0.1 to 180.1 μg/ml and from 0.1 to 257.2 μg/ml in patients with and without venous thromboembolism, respectively. The receiver operating characteristic curve was discriminative with a cut-off value of 3.3 μg/ml and an area under the curve of 0.794 (sensitivity, 0.742; specificity, 0.782; 95% confidence interval, 0.725-0.863).

CONCLUSIONS

This is the first study to calculate the D-dimer cut-off value in Japanese patients with advanced lung cancer. Patients with D-dimer levels ≥3.3 μg/ml at the time of initial diagnosis may have coexisting venous thromboembolism.

Machine Learning as a Diagnostic and Prognostic Tool for Predicting Thrombosis in Cancer Patients: A Systematic Review

Khorana score (KS) is an established risk assessment model for predicting cancer-associated thrombosis. However, it ignores several risk factors and has poor predictability in some cancer types. Machine learning (ML) is a novel technique used for the diagnosis and prognosis of several diseases, including cancer-associated thrombosis, when trained on specific diagnostic modalities. Consolidating the literature on the use of ML for the prediction of cancer-associated thrombosis is necessary to understand its diagnostic and prognostic abilities relative to KS. This systematic review aims to evaluate the current use and performance of ML algorithms to predict thrombosis in cancer patients. This study was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases Medline, EMBASE, Cochrane, and ClinicalTrials.gov, were searched from inception to September 15, 2023, for studies evaluating the use of ML models for the prediction of thrombosis in cancer patients. Search terms "machine learning," "artificial intelligence," "thrombosis," and "cancer" were used. Studies that examined adult cancer patients using any ML model were included. Two independent reviewers conducted study selection and data extraction. Three hundred citations were screened, of which 29 studies underwent a full-text review, and ultimately, 8 studies with 22,893 patients were included. Sample sizes ranged from 348 to 16,407 patients. Thrombosis was characterized as venous thromboembolism (n = 6) or peripherally inserted central catheter thrombosis (n = 2). The types of cancer included breast, gastric, colorectal, bladder, lung, esophageal, pancreatic, biliary, prostate, ovarian, genitourinary, head-neck, and sarcoma. All studies reported outcomes on the ML's predictive capacity. The extreme gradient boosting appears to be the best-performing model, and several models outperform KS in their respective datasets.

Cancer incidence and mortality after a first-ever venous thrombosis: a cohort study in northern Sweden

BACKGROUND

Venous thromboembolism (VTE) has a high mortality rate and can be the first manifestation of cancer. We investigated the incidence of cancer after first-ever VTE and the association between VTE and all-cause mortality.

METHODS

A Swedish cohort study that included 105,997 participants without previous cancer who underwent a health examination from 1985-2014 was conducted. Manually validated first-ever VTE events, incident cancer according to the Swedish cancer registry, and mortality were registered. Participants were followed until September 5, 2014.

RESULTS

The mean age at inclusion was 46.2 years, and 50.3% of participants were female. We identified 1303 persons in the cohort with a VTE and no previous cancer. Among these, 179 (13.7%) were diagnosed with cancer after the VTE event, resulting in a cancer incidence of 26.4 (95% CI 22.8-30.6) cases per 1000 person-years. The incidence was highest during the first 6 months after the VTE. In the study population, VTE was associated with an increased risk of cancer (HR 1.95 [95% CI 1.67-2.29] in a multivariable model). VTE was also associated with an increased risk of death (HR 6.30 [95% CI 5.82-6.81]) in a multivariable model). There was an interaction between sex and VTE in relation to both risk of cancer and mortality, with a stronger association in women.

CONCLUSIONS

The incidence of cancer is high after first-ever VTE, especially close to the VTE event. VTE seems to be a stronger risk marker in women than in men for both cancer and death.

Identification of key risk factors for venous thromboembolism in urological inpatients based on the Caprini scale and interpretable machine learning methods

PURPOSE

To identify the key risk factors for venous thromboembolism (VTE) in urological inpatients based on the Caprini scale using an interpretable machine learning method.

METHODS

VTE risk data of urological inpatients were obtained based on the Caprini scale in the case hospital. Based on the data, the Boruta method was used to further select the key variables from the 37 variables in the Caprini scale. Furthermore, decision rules corresponding to each risk level were generated using the rough set (RS) method. Finally, random forest (RF), support vector machine (SVM), and backpropagation artificial neural network (BPANN) were used to verify the data accuracy and were compared with the RS method.

RESULTS

Following the screening, the key risk factors for VTE in urology were "(C1) Age," "(C2) Minor Surgery planned," "(C3) Obesity (BMI > 25)," "(C8) Varicose veins," "(C9) Sepsis (< 1 month)," (C10) "Serious lung disease incl. pneumonia (< 1month) " (C11) COPD," "(C16) Other risk," "(C18) Major surgery (> 45 min)," "(C19) Laparoscopic surgery (> 45 min)," "(C20) Patient confined to bed (> 72 h)," "(C18) Malignancy (present or previous)," "(C23) Central venous access," "(C31) History of DVT/PE," "(C32) Other congenital or acquired thrombophilia," and "(C34) Stroke (< 1 month." According to the decision rules of different risk levels obtained using the RS method, "(C1) Age," "(C18) Major surgery (> 45 minutes)," and "(C21) Malignancy (present or previous)" were the main factors influencing mid- and high-risk levels, and some suggestions on VTE prevention were indicated based on these three factors. The average accuracies of the RS, RF, SVM, and BPANN models were 79.5%, 87.9%, 92.6%, and 97.2%, respectively. In addition, BPANN had the highest accuracy, recall, F1-score, and precision.

CONCLUSIONS

The RS model achieved poorer accuracy than the other three common machine learning models. However, the RS model provides strong interpretability and allows for the identification of high-risk factors and decision rules influencing high-risk assessments of VTE in urology. This transparency is very important for clinicians in the risk assessment process.

Comparison of rivaroxaban and low molecular weight heparin in the treatment of cancer-associated venous thromboembolism: a Swedish national population-based register study

BACKGROUND

Treating cancer-associated venous thromboembolism (CAT) with anticoagulation prevents recurrent venous thromboembolism (rVTE), but increases bleeding risk.

OBJECTIVES

To compare incidence of rVTE, major bleeding, and all-cause mortality for rivaroxaban versus low molecular weight heparin (LMWH) in patients with CAT.

METHODS

We developed a cohort study using Swedish national registers 2013-2019. Patients with CAT (venous thromboembolism within 6 months of cancer diagnosis) were included. Those with other indications or with high bleeding risk cancers were excluded (according to guidelines). Follow-up was from index-CAT until outcome, death, emigration, or end of study. Incidence rates (IR) per 1000 person-years with 95% confidence interval (CI) and propensity score overlap-weighted hazard ratios (HRs) for rivaroxaban versus LMWH were estimated.

RESULTS

We included 283 patients on rivaroxaban and 5181 on LMWH. The IR for rVTE was 68.7 (95% CI 40.0-109.9) for rivaroxaban, compared with 91.6 (95% CI 81.9-102.0) for LMWH, with adjusted HR 0.77 (95% CI 0.43-1.35). The IR for major bleeding was 23.5 (95% CI 8.6-51.1) for rivaroxaban versus 49.2 (95% CI 42.3-56.9) for LMWH, with adjusted HR 0.62 (95% CI 0.26-1.49). The IR for all-cause mortality was 146.8 (95% CI 103.9-201.5) for rivaroxaban and 565.6 (95% CI 541.8-590.2) for LMWH with adjusted HR 0.48 (95% CI 0.34-0.67).

CONCLUSIONS

Rivaroxaban performed similarly to LMWH for patients with CAT for rVTE and major bleeding. An all-cause mortality benefit was observed for rivaroxaban which potentially may be attributed to residual confounding.

TRIAL REGISTRATION NUMBER

NCT05150938 (Registered 9 December 2021).

Abdominal Aortic Aneurysm Repair in Patients with Concomitant Cancer: A Literature Review

OBJECTIVES

Abdominal aortic aneurysmal (AAA) repair in patients with concomitant cancer is controversial due to increased comorbidity and reduced life expectancy in this specific patient group. This literature review aims to investigate the evidence supporting one treatment modality over another (endovascular aortic repair (EVAR) or open repair (OR)), as well as treatment strategy (staged AAA-, cancer first or simultaneous procedures) in patients with AAA and concomitant cancer.

METHODS

Literature review, including studies published from 2000 to 2021 on surgical treatment in patients with AAA and concomitant cancer and related outcomes (30-day morbidity/complications as well as 30-day and 3-year mortality).

RESULTS

24 studies comprising 560 patients undergoing surgical treatment of AAA and concomitant cancer were included. Of these, 220 cases were treated with EVAR and 340 with OR. Simultaneous procedures were performed in 190 cases, 370 received staged procedures. The 30-day mortality for EVAR versus OR was 1% and 8%, corresponding to a relative risk (RR) of 0.11 (95% CI: 0.03-0.46, p = 0.002). No difference in mortality was observed between staged versus simultaneous procedure nor between AAA-first versus cancer-first strategy, RR 0.59 (95% CI: 0.29-1.1, p = 0.13) and 0.88 (95% CI 0.34-2.31, p = 0.80), respectively. Overall, 3-year mortality was 21% for EVAR and 39% for OR from 2000-2021, while the mortality up to 3 years after EVAR within recent years (2015-2021) was 16%.

CONCLUSION

This review supports EVAR treatment as first choice if suitable. No consensus was established on treating either the aneurysm or the cancer first or simultaneously. Long-term mortality after EVAR was comparable to non-cancer patients within recent years.

Increased risk of cardiovascular disease among kidney cancer survivors: a nationwide population-based cohort study

Background

Cardiovascular disease (CVD) is a major concern of morbidity and mortality among cancer survivors. However, few evidence exists on the short- and long-term risk of CVD in kidney cancer (KCa) survivors.

Methods

In this nationwide, large population-based retrospective cohort study, we used the Korean national health insurance and medical checkup survey linkage database (2007-2021), drawn from the entire Korean population. We included adults diagnosed with KCa as the first primary cancer and matched them to an individual without KCa at a 1:5 ratio. The primary outcome was CVD incidence, including myocardial infarction, stroke, atrial fibrillation, heart failure, peripheral arterial occlusion, and venous thromboembolism (VTE). We evaluated CVD risk at 6 months, 1 year, and 5 years following cancer diagnosis, using Fine-Gray competing risk models that accounted for death as a competing factor.

Results

A total of 149,232 participants were included (KCa survivors: N=20,093 and matched non-KCa individuals: N=129,139). After 6-month follow-up, KCa survivors showed an increased risk of CVD compared to the general population (subdistribution hazard ratio (HR) 2.70, 95% confidence interval (CI) 2.31-3.15). After 1 year, KCa survivors had a higher risk of CVD (HR=1.77, 95% CI: 1.56-2.00). After 5 years, this elevated CVD risk remained (HR=1.10, 95% CI: 1.03-1.18), with VTE identified as the primary contributing disease (HR=3.05, 95% CI:2.59-3.59).

Conclusion

KCa survivors had an increased risk of CVD up to 5 years after cancer diagnosis compared to the general population. Our findings emphasize the importance of comprehensive healthcare management for both CVD and KCa throughout cancer survivorship.

Integrated pan-cancer and scRNA-seq analyses identify a prognostic coagulation-related gene signature associated with tumor microenvironment in lower-grade glioma

Cancer-associated thrombosis is a significant complication in cancer patients, leading to increased morbidity and mortality. The expression of coagulation/fibrinolysis genes, termed the "coagulome", plays a critical role in this process. Using the single-sample gene set enrichment analysis (ssGSEA), we identified seven cancer types with significantly activated coagulation pathways, focusing on lower-grade glioma (LGG) and stomach adenocarcinoma due to their predictive value for overall survival. Through 1000 iterations of the Least Absolute Shrinkage and Selection Operator (LASSO), we selected prognostic genes and constructed effective Cox regression models, particularly for LGG. Incorporating clinical characteristics, we constructed a nomogram for LGG, achieving an impressive area under the curve (AUCs) of 0.79, 0.82, and 0.81 at 1, 3, and 5 years in the test dataset, indicating strong potential for clinical application. Functional enrichment analysis between high-risk and low-risk LGG groups revealed significant enrichment of genes involved in the inflammatory response, interferon-gamma response, and epithelial-mesenchymal transition pathways. Combined with CIBERSORT and single-cell RNA sequencing analysis of LGG, our results demonstrated that the interplay between coagulation and the tumor microenvironment, particularly involving gliomas and myeloid cells, significantly influences tumor progression and patient outcomes.

Vascular events in patients with head and neck cancer: A systematic review and meta-analysis

OBJECTIVE

To assess the incidence of vascular events in patients with head and neck cancer.

REVIEW METHODS

Primary studies identified through April 2023. Meta-analysis was performed.

RESULTS

There were 146 studies included in the systematic review. Rates of events were collected in the overall group, those with chemoprophylaxis, and those that underwent surgery, radiation, or chemotherapy. Of 1 184 160 patients, 4.3% had a vascular event. Radiation therapy had highest risk of overall events and stroke when compared to surgery and chemotherapy. Chemotherapy had a higher risk of stroke and overall events when compared to surgery.

CONCLUSIONS

Vascular events occur in 4%-5% of patients with head and neck cancer. Our data does not support the use of routine anticoagulation. Patients undergoing radiation therapy had the highest frequency of events.

Pitfalls of ultrasound for deep vein thrombosis of the lower extremities

Venous ultrasound is the primary, widely accepted diagnostic tool to assess deep vein thrombosis (DVT) in the lower extremities. However, other focal lesions in the lower extremities can be identified on ultrasound. The sonographic appearance of these abnormalities may overlap the thrombosis, which included vascular tumors, Baker's cyst, hematoma, cancer thrombosis, and peripheral nerve tumors. This essay derives from cases diagnosed in our centers and published literature, with images available for illustrations, which may help to improve the clinical management of these findings.

Cardiovascular Safety of COVID-19 Vaccination in Patients With Cancer: A Self-Controlled Case Series Study in Korea

BACKGROUND

Cancer patients have an increased risk of cardiovascular outcomes and are susceptible to coronavirus disease 2019 (COVID-19) infection. We aimed to assess the cardiovascular safety of COVID-19 vaccination for cancer patients in South Korea.

METHODS

We conducted a self-controlled case series study using the K-COV-N cohort (2018-2021). Patients with cancer aged 12 years or older who experienced cardiovascular outcomes were identified. Cardiovascular outcomes were defined as myocardial infarction, stroke, venous thromboembolism (VTE), myocarditis, or pericarditis, and the risk period was 0-28 days after receiving each dose of COVID-19 vaccines. A conditional Poisson regression model was used to calculate the incidence rate ratio (IRR) with 95% confidence interval (CI).

RESULTS

Among 318,105 patients with cancer, 4,754 patients with cardiovascular outcomes were included. The overall cardiovascular risk was not increased (adjusted IRR, 0.99 [95% CI, 0.90-1.08]) during the whole risk period. The adjusted IRRs of total cardiovascular outcomes during the whole risk period according to the vaccine type were 1.07 (95% CI, 0.95-1.21) in the mRNA vaccine subgroup, 0.99 (95% CI, 0.83-1.19) in the ChAdOx1 nCoV-19 vaccine subgroup, and 0.86 (95% CI, 0.68-1.10) in the mix-matched vaccination subgroup. However, in the analysis of individual outcome, the adjusted IRR of myocarditis was increased to 11.71 (95% CI, 5.88-23.35) during the whole risk period. In contrast, no increased risk was observed for other outcomes, such as myocardial infarction, stroke, VTE, and pericarditis.

CONCLUSION

For cancer patients, COVID-19 vaccination demonstrated an overall safe profile in terms of cardiovascular outcomes. However, caution is required as an increased risk of myocarditis following COVID-19 vaccination was observed in this study.

Effects of PCSK9 on thrombosis and haemostasis in a variety of metabolic states: Lipids and beyond (Review)

Proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors are widely recognised as being able to induce a potent reduction in low‑density lipoprotein‑cholesterol. An increasing number of studies have suggested that PCSK9 also influences the haemostatic system by altering platelet function and the coagulation cascade. These findings have significant implications for anti‑PCSK9 therapy in patients with specific coagulation conditions, including expanded indications, dose adjustments and drug interactions. The present review summarises the changes in PCSK9 levels in individuals with liver diseases, chronic kidney diseases, diabetes mellitus, cancer and other disease states, and discusses their impact on thrombosis and haemostasis. Furthermore, the structure, effects and regulatory mechanisms of PCSK9 on platelets, coagulation factors, inflammatory cells and endothelial cells during coagulation and haemostasis are described.

Pulmonary Embolism in a Young African American Male: A Diagnostic Challenge

This case report highlights the diagnostic challenges posed by pulmonary embolism (PE) in a young, otherwise healthy 33-year-old African American male with no apparent risk factors. The patient presented with penile pain, swelling, hematuria, flank pain, and rash, and was admitted for balanoposthitis and acute urinary retention. Despite prophylactic heparin, he suffered two cardiac arrests secondary to PE on the fifth day of hospitalization. Prompt thrombolytic therapy and heparin infusion were initiated, but his course was complicated by anuric acute kidney injury requiring hemodialysis, shock liver, and gastrointestinal bleeding. Imaging revealed a substantial thrombus burden in the pulmonary arteries. Notably, a hypercoagulable workup was negative. The absence of typical risk factors, negative hypercoagulable workup, and occurrence of PE despite prophylaxis underscore the importance of vigilance in recognizing atypical presentations. This case emphasizes the need for a high index of suspicion and comprehensive evaluation to diagnose PE in young patients without clear predisposing factors.

Multi-organ Thromboembolic Crisis: A Case Report of Concomitant Stroke, Myocardial Infarction, and Pulmonary Embolism

Management of acute coronary syndrome (ACS), cerebrovascular accident (CVA), and pulmonary embolism (PE) necessitates prompt intervention, as delayed treatment may lead to severe consequences. Each of these conditions presents significant challenges and carries a high risk of morbidity and mortality. We present the case of an 86-year-old female with a history of stage 4 urothelial carcinoma metastasized to the lungs, who presented to the emergency department (ED) with acute ischemic stroke (AIS), ST-segment elevation myocardial infarction (STEMI), and bilateral PE. We propose the term "multi-organ thromboembolic crisis" (MOTEC) to streamline the communication and management approach for patients experiencing critical thromboembolic events affecting multiple organ systems.

Haemostatic gene variations in cervical cancer-associated venous thrombosis: considerations for clinical strategies

Venous thromboembolism (VTE) is a life-threatening haemostatic disease frequently diagnosed among the cancer population. The Khorana Score is currently the primal risk assessment model to stratify oncological patients according to their susceptibility to VTE, however, it displays a limited performance. Meanwhile, intensive research on VTE pathophysiology in the general population has uncovered a range of single-nucleotide polymorphisms (SNPs) associated with the condition. Nonetheless, their predictive ability concerning cancer-associated thrombosis (CAT) is controversial. Cervical cancer (CC) patients undergoing chemoradiotherapy often experience VTE, which negatively affects their survival. Thus, aiming for an improvement in thromboprophylaxis, new thrombotic biomarkers, including SNPs, are currently under investigation. In this study, the predictive capability of haemostatic gene SNPs on CC-related VTE and their prognostic value regardless of VTE were explored. Six SNPs in haemostatic genes were evaluated. A total of 401 CC patients undergoing chemoradiotherapy were enrolled in a retrospective cohort study. The implications for the time to VTE occurrence and overall survival (OS) were assessed. CAT considerably impacted the CC patients' OS (log-rank test, P < 0.001). SERPINE1 rs2070682 (T > C) showed a significant association with the risk of CC-related VTE (CC/CT vs. TT, log-rank test, P = 0.002; C allele, Cox model, hazard ratio (HR) = 6.99 and P = 0.009), while F2 rs1799963 (G > A) demonstrated an important prognostic value regardless of VTE (AA/AG vs. GG, log-rank test, P = 0.020; A allele, Cox model, HR = 2.76 and P = 0.026). For the remaining SNPs, no significant associations were detected. The polymorphisms SERPINE1 rs2070682 and F2 rs1799963 could be valuable tools in clinical decision-making, aiding in thromboprophylaxis and CC management, respectively.

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.

Pancreatic Cancer and Venous Thromboembolism

Pancreatic ductal adenocarcinoma (PDAC) accounts for more than 90% of all pancreatic cancers and is the most fatal of all cancers. The treatment response from combination chemotherapies is far from satisfactory and surgery remains the mainstay of curative strategies. These challenges warrant identifying effective treatments for combating this deadly cancer. PDAC tumor progression is associated with the robust activation of the coagulation system. Notably, cancer-associated thrombosis (CAT) is a significant risk factor in PDAC. CAT is a concept whereby cancer cells promote thromboembolism, primarily venous thromboembolism (VTE). Of all cancer types, PDAC is associated with the highest risk of developing VTE. Hypoxia in a PDAC tumor microenvironment also elevates thrombotic risk. Direct oral anticoagulants (DOACs) or low-molecular-weight heparin (LMWH) are used only as thromboprophylaxis in PDAC. However, a precision medicine approach is recommended to determine the precise dose and duration of thromboprophylaxis in clinical setting.

Contribution of Endothelial Dysfunction to Cancer Susceptibility and Progression: A Comprehensive Narrative Review on the Genetic Risk Component

Venous thromboembolism (VTE) is a challenging clinical obstacle in oncological settings, marked by elevated incidence rates and resulting morbidity and mortality. In the context of cancer-associated thrombosis (CAT), endothelial dysfunction (ED) plays a crucial role in promoting a pro-thrombotic environment as endothelial cells lose their ability to regulate blood flow and coagulation. Moreover, emerging research suggests that this disorder may not only contribute to CAT but also impact tumorigenesis itself. Indeed, a dysfunctional endothelium may promote resistance to therapy and favour tumour progression and dissemination. While extensive research has elucidated the multifaceted mechanisms of ED pathogenesis, the genetic component remains a focal point of investigation. This comprehensive narrative review thus delves into the genetic landscape of ED and its potential ramifications on cancer progression. A thorough examination of genetic variants, specifically polymorphisms, within key genes involved in ED pathogenesis, namely eNOS, EDN1, ACE, AGT, F2, SELP, SELE, VWF, ICAM1, and VCAM1, was conducted. Overall, these polymorphisms seem to play a context-dependent role, exerting both oncogenic and tumour suppressor effects depending on the tumour and other environmental factors. In-depth studies are needed to uncover the mechanisms connecting these DNA variations to the pathogenesis of malignant diseases.

Identifying novel biomarkers using proteomics to predict cancer-associated thrombosis

Comprehensive protein analyses of plasma are made possible by high-throughput proteomic screens, which may help find new therapeutic targets and diagnostic biomarkers. Patients with cancer are frequently affected by venous thromboembolism (VTE). The limited predictive accuracy of current VTE risk assessment tools highlights the need for new, more targeted biomarkers. Although coagulation biomarkers for the diagnosis, prognosis, and treatment of VTE have been investigated, none of them have the necessary clinical validation or diagnostic accuracy. Proteomics holds the potential to uncover new biomarkers and thrombotic pathways that impact the risk of thrombosis. This review explores the fundamental methods used in proteomics and focuses on particular biomarkers found in VTE and cancer-associated thrombosis.

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.

Absence of Hypercoagulation Status after Neoadjuvant Treatment is Associated with Favorable Prognosis in Patients Undergoing Subtotal Esophagectomy for Esophageal Squamous Cell Carcinoma

BACKGROUND

Abnormal activation of the coagulation system is associated with malignant tumor progression. Although neoadjuvant treatment (NAT) for resectable esophageal squamous cell carcinoma (ESCC) is the standard of care, the correlation between coagulation status and prognosis of patients undergoing preoperative treatment is insufficiently understood.

METHODS

Patients (n = 200) who underwent radical subtotal esophagectomy after preoperative treatment for ESCC between January 2012 and December 2021were included in the analysis. Plasma D-dimer and fibrinogen levels and their combined indices (non-hypercoagulation; D-dimer and fibrinogen levels within the upper normal limit, or hypercoagulation; D-dimer or fibrinogen levels above the upper normal limit) were determined before and after NAT and correlated to clinicopathological factors and prognosis.

RESULTS

The nonhypercoagulation group achieved superior overall survival (OS) than the hypercoagulation group (5-year OS rates = 89% vs. 55%; hazard ratio 3.62, P = 0.0008) when determined according to coagulation status after NAT. Multivariate analysis showed that hypercoagulation after NAT served as an independent factor for poor postoperative OS (hazard ratio 3.20; P = 0.0028). The nonhypercoagulation group achieved significantly better disease-free survival (76% vs. 54%; P = 0.0065) than the hypercoagulation group that experienced a significantly higher rate of hematogenous metastasis as an initial recurrence (P = 0.0337).

CONCLUSIONS

Hypercoagulation state after NAT served as a valid indicator correlating with postoperative outcomes of patients with ESCC who underwent NAT followed by radical subtotal esophagectomy.

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.

High levels of soluble P-selectin, neutrophil extracellular traps, and myeloperoxidase as risk factor of deep vein thrombosis in malignancy patients receiving platinum-based chemotherapy

Backgrounds

Venous Thromboembolism (VTE) is a disease entity comprising Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE). VTE events increase the mortality rate of patients with cancer receiving platinum-based chemotherapy. Soluble P-Selectin, Neutrophil Extracellular Traps (NET), and myeloperoxidase (MPO) are risk factors associated with DVT in malignancy patients receiving platinum-based chemotherapy. The purpose of this study was to determine the role of soluble P-selectin, NET, and MPO as risk factors for DVT in patients with malignancy receiving platinum-based chemotherapy.

Patients and Methods

This study used a case-control design (matched pair case-control study) based on age and gender. The case group consisted of subjects with DVT, whereas the control group consisted of subjects without DVT. The subjects were 31 in each case and control groups. Soluble P-selectin, NET, and MPO levels were measured in each group.

Results

The mean age of case group was 50.26±12.15 years meanwhile in control group was 52.81±11.64 years. In the case group, 71% of the subjects were female, whereas 51.6% of the control group were male. Most subjects, either in the case group (71%) or the control group (71%), used carboplatin. In the case group, cervix malignancy was the most common malignancy (32.3%), whereas in the control group, it was nasopharyngeal malignancy (25.8%). High soluble P-selectin level was a risk factor for DVT (OR 3.38, CI 1.180 - 9.780, p=0.02). A high NET level was also a risk factor for DVT (OR 2.88, CI 1.026-8.074, p=0.04). The high MPO levels in this study could not be proven as a risk factor.

Conclusions

Soluble P-selectin and NET are risk factors that play a role in the pathophysiology of DVT through the pathomechanism of immunothrombosis induced by endothelial injury and activation of monocytes and neutrophils due to the use of platinum-based chemotherapy.

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.

Risk of Venous Thromboembolism by Cancer Type: A Network Meta-Analysis

Patients with cancer have an increased risk of venous thromboembolism (VTE). Comparing tumor-specific VTE risk is complicated by factors such as surgery, disease stage, and chemotherapy. Network meta-analysis (NMA) using cancer types as network nodes enabled us to estimate VTE rates by leveraging comparisons across cancer types while adjusting for baseline VTE risk in individual studies. This study was conducted to estimate the risk of VTE by cancer type and factors influencing VTE risk. The Embase, MEDLINE, and Cochrane Library repositories were systematically searched to identify clinical trials and observational studies published from 2005 to 2022 that assessed the risk of primary cancer-related VTE among two or more distinct cancer types. Studies with similar cancer populations and study methods reporting VTE occurring within 1 year of diagnosis were included in the NMA. Relative VTE rates across cancer types were estimated with random-effects Bayesian NMAs. Absolute VTE rates were calculated from these estimates using the average VTE incidence in lung cancer (the most frequently reported type) as the "anchor." From 2,603 records reviewed, 30 studies were included in this NMA. The general network described 3,948,752 patients and 18 cancer types: 3.1% experienced VTE within 1 year of diagnosis, with cancer-specific rates ranging from 0.7 to 7.4%. Consistent with existing VTE risk prediction tools, pancreatic cancer was associated with higher-than-average VTE risk. Other cancer types with high VTE risk were brain and ovarian cancers. The relative rankings of VTE risk for certain cancers changed based on disease stage and/or receipt of chemotherapy or surgery.