The potential link between Covid-19 and multiple myeloma: A new saga

BACKGROUND

Covid-19 is considered a primary respiratory disease-causing viral pneumonia and, in severe cases, leads to acute lung injury and acute respiratory distress syndrome (ARDS). In addition, though, extra-pulmonary manifestations of Covid-19 have been shown. Furthermore, severe acute respiratory distress syndrome coronavirus type 2 (SARS-CoV-2) infection may coexist with several malignancies, including multiple myeloma (MM).

METHODS

This critical literature review aimed to find the potential association between SARS-CoV-2 infection and MM in Covid-19 patients with underlying MM. Narrative literature and databases search revealed that ARDS is developed in both MM and Covid-19 due to hypercalcemia and proteasome dysfunction.

RESULTS

Notably, the expression of angiogenic factors and glutamine deficiency could link Covid-19 severity and MM in the pathogenesis of cardiovascular complications. MM and Covid-19 share thrombosis as a typical complication; unlike thrombosis in Covid-19, which reflects disease severity, thrombosis does not reflect disease severity in MM. In both conditions, thromboprophylaxis is essential to prevent pulmonary thrombosis and other thromboembolic disorders. Moreover, Covid-19 may exacerbate the development of acute kidney injury and neurological complications in MM patients.

CONCLUSION

These findings highlighted that MM patients might be a risk group for Covid-19 severity due to underlying immunosuppression and most of those patients need specific management in the Covid-19 era.

Association of anticoagulant use with clinical outcomes from crizotinib in ALK- and ROS1-rearranged advanced non-small cell lung cancers: A retrospective analysis of PROFILE 1001

BACKGROUND

ROS1- and ALK-rearranged advanced NSCLCs are associated with increased thromboembolic risk. We hypothesized that a prothrombotic phenotype offers an evolutionary advantage to subsets of these cancers. The impact of this phenotype could alter outcomes from targeted therapy.

METHODS

In a retrospective analysis of ROS1- and ALK-rearranged NSCLCs treated with crizotinib in a phase 1 trial, we compared progression-free survival (PFS) and objective response rate (ORR) based on the history of anticoagulation use (a possible surrogate of thromboembolism) at baseline (within 90 days before study enrollment) or within 90 days of study treatment.

RESULTS

Twelve out of 53 (22.6%) ROS1- and 39 out of 153 (25.5%) ALK-rearranged NSCLCs received anticoagulation before or during the trial. Most ROS1 and ALK patients on anticoagulation received low-molecular-weight heparin (75% and 64.1%, respectively). In the ROS1-rearranged group, the median PFS (95% CI) values were 5.1 (4.4-14.4) and 29.0 (16.5-48.8) months, and the ORR values were 41.7% (95% CI: 15.2 to 72.3) and 80.5% (95% CI: 65.1 to 91.2) among those with and without anticoagulation treatment, respectively. In the ALK-rearranged group, the median PFS (95% CI) was 7.1 (5.4-7.7) and 12.0 (9.4-18.3) months, and the ORR was 41% (95% CI: 25.6 to 57.9) and 74.3% (95% CI: 65.3 to 82.1) among those with and without anticoagulation, respectively.

CONCLUSIONS

Anticoagulation (as a potential surrogate of a prothrombotic subset) in ROS1- and ALK-rearranged NSCLCs may be associated with a lower PFS and ORR to crizotinib.

CLINICALTRIAL

gov: NCT00585195.

Multiple organ infarction caused by aortic thrombus in a lung cancer patient with the BRAF mutation

A 72-year-old male patient with advanced lung adenocarcinoma harboring a BRAF mutation had received treatment with a BRAF inhibitor and a MEK inhibitor. Treatment was ceased after 40 days because of disease progression. Twenty-four days after treatment cessation, the man was referred to our hospital with worsening abdominal and back pain over 2 weeks. Computed tomography revealed a massive thrombus in the descending aorta, bilateral kidney infarction, splenic infarction, and intestinal enlargement due to ileus. He was diagnosed with multiple organ infarction caused by arterial thromboembolism. Tumors harboring BRAF mutations and BRAF/MEK inhibitor therapy both have the potential to increase thrombosis risk, and were therefore thought to be associated with the occurrence of aortic thrombosis.

Tumour-host interactions through the lens of Drosophila

There is a large gap between the deep understanding of mechanisms driving tumour growth and the reasons why patients ultimately die of cancer. It is now appreciated that interactions between the tumour and surrounding non-tumour (sometimes referred to as host) cells play critical roles in mortality as well as tumour progression, but much remains unknown about the underlying molecular mechanisms, especially those that act beyond the tumour microenvironment. Drosophila has a track record of high-impact discoveries about cell-autonomous growth regulation, and is well suited to now probe mysteries of tumour - host interactions. Here, we review current knowledge about how fly tumours interact with microenvironmental stroma, circulating innate immune cells and distant organs to influence disease progression. We also discuss reciprocal regulation between tumours and host physiology, with a particular focus on paraneoplasias. The fly's simplicity along with the ability to study lethality directly provide an opportunity to shed new light on how cancer actually kills.

Development and validation of a predictive score for venous thromboembolism in newly diagnosed non-small cell lung cancer

INTRODUCTION

The risk of venous thromboembolism (VTE) varies among tumour types, and different cancer type-specific risks for VTE prediction remain undefined. We aimed to establish a prediction model for non-small lung cancer (NSCLC)-associated VTE.

MATERIALS AND METHODS

We analysed data from a prospective cohort of patients with newly diagnosed NSCLC. We then developed a VTE risk prediction model using data of patients who were recruited from 2013 to 2017 (n = 602, development cohort) and validated this model using date of patients recruited from 2018 to 2019 (n = 412, validation cohort). The cumulative 6 months VTE incidence observed in both cohorts was calculated.

RESULTS

The parameters in this new model included Eastern Cooperative Oncology Group (ECOG) performance status ≥2 (1 point), EGFR mutation (-1 point), neutrophil count ≥7.5 × 10⁹/L (2 points), hemoglobin <115 g/L (1 point), CEA ≥5.0 ng/mL (2 points), and D-dimer level ≥1400 ng/mL (4 points). The cross-validated concordance indices of the model in the development and validation cohorts were 0.779 and 0.853, respectively. Furthermore, the areas under the curve in the two cohorts were 0.7563 (95% confidence interval [CI]: 0.6856-0.8129, P < 0.001) and 0.8211 (95% CI: 0.7451-0.8765, P < 0.001) for development and validation cohorts, respectively.

CONCLUSIONS

The new VTE risk prediction model incorporated patient characteristics, laboratory values, and oncogenic status, and was able to stratify patients at high risk of VTE in newly diagnosed NSCLC within 6 months of diagnosis.

Tumor-induced disruption of the blood-brain barrier promotes host death

Cancer patients often die from symptoms that manifest at a distance from any tumor. Mechanisms underlying these systemic physiological perturbations, called paraneoplastic syndromes, may benefit from investigation in non-mammalian systems. Using a non-metastatic Drosophila adult model, we find that malignant-tumor-produced cytokines drive widespread host activation of JAK-STAT signaling and cause premature lethality. STAT activity is particularly high in cells of the blood-brain barrier (BBB), where it induces aberrant BBB permeability. Remarkably, inhibiting STAT in the BBB not only rescues barrier function but also extends the lifespan of tumor-bearing hosts. We identify BBB damage in other pathological conditions that cause elevated inflammatory signaling, including obesity and infection, where BBB permeability also regulates host survival. IL-6-dependent BBB dysfunction is further seen in a mouse tumor model, and it again promotes host morbidity. Therefore, BBB alterations constitute a conserved lethal tumor-host interaction that also underlies other physiological morbidities.

Blocking VCAM-1 inhibits pancreatic tumour progression and cancer-associated thrombosis/thromboembolism

OBJECTIVE

Pancreatic ductal adenocarcinoma (PDAC) is the deadliest cancer. Cancer-associated thrombosis/thromboembolism (CAT), frequently observed in PDAC, is known as a poor prognostic factor. Here, we investigated the underlying mechanisms between PDAC and CAT, and performed a trial of therapeutic approach for PDAC using a genetically engineered mouse model, PKF (Ptf1a^cre/+;LSL-Kras^G12D/+;Tgfbr2^flox/flox ).

DESIGN

Presence of CAT in PKF mice was detected by systemic autopsy. Plasma cytokines were screened by cytokine antibody array. Murine and human plasma atrial natriuretic peptide (ANP) and soluble vascular cell adhesion molecule 1 (sVCAM-1) were determined by ELISA. Distribution of VCAM-1 in PKF mice and human autopsy samples was detected by immunohistochemistry. PKF mice were treated with anti-VCAM-1 antibody and the effects on survival, distribution of CAT and the tumour histology were analysed.

RESULTS

We found spontaneous CAT with cardiomegaly in 68.4% PKF mice. Increase of plasma ANP and sVCAM-1 was observed in PKF mice and PDAC patients with CAT. VCAM-1 was detected in the activated endothelium and thrombi. Administration of anti-VCAM-1 antibody to PKF mice inhibited tumour growth, neutrophil/macrophage infiltration, tumour angiogenesis and progression of CAT; moreover, it dramatically extended survival (from 61 to 253 days, p<0.01).

CONCLUSION

Blocking VCAM-1/sVCAM-1 might be a potent therapeutic approach for PDAC as well as CAT, which can contribute to the prognosis. Increase of plasma ANP and sVCAM-1 might be a diagnostic approach for CAT in PDAC.

A comprehensive review of DOACs for cancer associated VTE prophylaxis or treatment

Cancer is a leading cause of venous thromboembolism (VTE), which contributes to significant morbidity and mortality in these patients. Increased thrombotic risk in cancer patients is modified by tumor-specific biology, disease-directed interventions, and individual comorbidities. Risk stratification for prophylaxis and treatment requires regular reevaluation of these factors, which can be facilitated by validated prediction tools. This review also discusses large clinical trial data (SELECT-D, HOKUSAI-VTE, ADAM VTE, CARAVAGGIO) demonstrating that direct oral anticoagulants (DOACs) are effective in the treatment of cancer-associated VTE, with comparable efficacy to the traditional choice of low molecular weight heparin. In the prophylactic setting derived from patients with cancer with increased VTE risk, DOACs also reduced the incidence of VTE with only modest increases in bleeding risk. The ease of DOAC administration and acceptable risk profile in the carefully selected patient make them an appealing choice for anticoagulation. In instances where the risk of gastrointestinal bleeding is of concern, apixaban, in particular, may still be a suitable option in place of LMWH. These improvements in our anticoagulation approach to cancer-associated VTE are well-timed to accompany the recent advances in disease-directed therapies that are enabling patients to live longer with cancer and therefore at increased risk of complications such as VTE.

Incidence of venous thromboembolism in patients with colorectal cancer according to oncogenic status

BACKGROUND

There are conflicting data regarding the role of KRAS mutation on the risk of venous thromboembolism (VTE) in colorectal cancer (CRC) patients. Moreover, the role of other biomarkers such as NRAS or BRAF has not been studied.

PURPOSE

To analyze the incidence of VTE in a cohort of patients with CRC based on KRAS, NRAS, and BRAF status.

METHODS

We performed a retrospective review of patients with unresectable locally advanced and metastatic CRC (mCRC) and known KRAS/NRAS/BRAF status, attended in the Medical Oncology Department of the Hospital General Universitario Gregorio Marañón (Madrid, Spain). The primary outcome was VTE defined as any venous thromboembolic event that occurred either 6 months before or at any time after the diagnosis of CRC. The biomarker status (KRAS, NRAS, and BRAF) and other predictors of thrombosis were collected.

RESULTS

One hundred and ninety-four patients were identified and included in the analysis. Forty-one patients (21.1%) experienced VTE. The incidence was 19.1% in RAS-mutated patients, 28.6% in BRAF-mutated patients and 21% in triple wild-type patients (p = NS). In multivariate analysis, ECOG ≥ 2 was the only independent predictor of VTE (OR 8.73; CI 95% 1.32-57.82; p = 0.025).

CONCLUSIONS

In our study, biomarkers have not been associated with an increased risk of VTE in CRC patients. A high incidence of VTE in BRAF-mutated patients has been observed and should be explored in further studies.

Association of ALK rearrangement and risk of venous thromboembolism in patients with non-small cell lung cancer: A prospective cohort study

BACKGROUND

Isolated reports are inconsistent regarding the risk of venous thromboembolism (VTE) in patients with anaplastic lymphoma kinase (ALK) rearranged non-small cell lung cancer (NSCLC). This study examined whether ALK rearrangement could have an influence on VTE in a prospective cohort.

METHODS

In a cohort of 836 consecutive patients with NSCLC, patients with epidermal growth factor receptor (EGFR) or kitten rat sarcoma (KRAS) mutations were ruled out for VTE interference. Finally, 341 qualified patients were observed. The median follow up period is 7.5 months (3.1-15.4m). ALK rearrangement was detected by fluorescence in situ hybridization at baseline.

RESULTS

Overall VTE events occurred in 37 (10.9%) of 341 patients. In multivariable analysis including age, sex, tumor histology, tumor stage, performance status, and ALK status, ALK rearrangement (sub-distribution hazard radio 2.47, 95% confidence interval 1.04-5.90) was associated with the increased risk of VTE. The cumulative incidence of VTE was 26.9% and 9.2% in the patients with and without ALK rearrangement after 6 months. After 1 year the corresponding cumulative incidence was 26.9% and 9.7% respectively (Gray test P = .005).

CONCLUSIONS

The presence of ALK rearrangement is associated with increased risk of VTE in patients with NSCLC.

Assessment of preoperative hypercoagulability in patients with pancreatic ductal adenocarcinoma (PDAC) using rapid thromboelastography (r-TEG)

Patients with malignant tumors are usually accompanied with hypercoagulability state and high incidence risk of venous thromboembolism (VTE), especially in patients with pancreatic ductal adenocarcinoma (PDAC). However, conventional coagulation test is failed to identify this abnormity. We retrospectively reviewed clinical data of 78 PDAC patients and 79 age-matched controls with rapid thromboelastography (r-TEG) and conventional coagulation test. The main index of r-TEG include TEG-ACT (second), R (second), K (second), angleα (°) and MA (mm), and a short TEG-ACT, short R, a short K, a broad angleα and a prolonged MA can identify hypercoagulability. Compared with age-matched controls, the PADC patients were analyzed to have a shorter K value (72. + 24 ± 22.90 vs. 85.63 ± 32.81, P = 0.0014), increased angleα value (76.20 ± 3.68 vs. 74.415 ± 4.73, P = 0.009) and MA value (63.33 ± 7.19 vs. 60.89 ± 5.52, P = 0.18). Both TEG-ACT (101.72 ± 7.57 vs. 103.78 ± 7.33, P = 0.086) and R (32.95 ± 4.72 vs. 34.34 ± 4.61, P = 0.085) value showed no significant difference in two groups. The laboratory values for conventional coagulation test were within normal ranges: PT (11.65 ± 0.95 vs. 11.38 ± 0.79, P = 0.049), INR (1.01 ± 0.09 vs. 0.98 ± 0.08, P = 0.101), aPTT (28.75 ± 3.45 vs. 28.00 ± 2.98, P = 0.149) and TT (19.44 ± 1.12 vs. 19.69 ± 1.35, P = 0.212). Incidence rates of VTE were 3.8% (3 of 78 patients) and 1.3% (1 of 79 patients) respectively (Fisher's exact test: P = 0.367). Several r-TEG indexes can indicate coagulation disorders within PDAC patients, but the incidence rates of VTE for both PDAC patients and normal controls had no significant difference. Compare to the control group, the potential hypercoagulability of PDAC patients did not correlate to thrombotic complications.

Coagulation in Brain Tumors: Biological Basis and Clinical Implications

Cancer patients commonly show abnormal laboratory coagulation tests, indicating a subclinical hypercoagulable condition that contribute to morbidity and mortality. The hypercoagulation status not only increases the risk of thromboembolic events but also influences the tumor biology promoting its growth and progression by stimulating intracellular signaling pathways. Recent molecular studies characterized the role of oncogene and suppressor gene in activating clotting pathways, as an integral feature of the neoplastic transformation. It is now clear how haemostatic processes, activated by cancer cells harboring oncogenic mutations, rely on the molecular profile of a particular malignancy, an aspect particularly evident in the differential coagulome profiles showed by different molecular subtypes of brain tumors, such as glioblastoma and medulloblastoma. This review focuses on the biological and clinical aspects of haemostasis in cancer with particular regard on brain tumors.

Differing mechanisms of thrombin generation in live haematological and solid cancer cells determined by calibrated automated thrombography

: Calibrated automated thrombography (CAT) is emerging as a reliable tool for real-time estimation of thrombin generation potential. There is a clinical need for knowledge about the pathways underlying the thrombotic phenotype of different malignancies. Cells from solid (e.g. pancreatic cancer; n = 7) and malignant haematological cell lines (e.g. multiple myeloma; n = 5) were evaluated for thrombin generation, using CAT, with the addition of control plasma (NormTrol; Helena Biosciences, Gateshead, UK)) or plasma deficient in coagulation factors VII and XII. In addition, tissue factor (TF) cell surface expression was determined by flow cytometry. In platelet-free plasma, thrombin generation in all cancer cell lines was cell concentration dependent, with the pancreatic cancer line CFPAC-1 producing the highest thrombin of 220 nmol/l at 5 × 10-cells/ml concentration. Lag times and times to peak reflected most significant differences out of all thrombin generation parameters measured and were inversely correlated with cell surface TF surface expression. Solid tumour cell lines had higher thrombin peaks, faster lag times, and a thrombin generation profile of overall greater magnitude than haematological cell lines. In the absence of factor VII in platelet-free plasma, thrombin generation in solid pancreatic cancer cell lines was significantly reduced unlike in haematological cell lines. However, in the absence of factor XII, thrombin generation was reduced more in haematological cells but had little or no effect on solid cell lines. The CAT assay identified characteristic differences in thrombin generation kinetics between solid tumour and haematological cancer cell lines, of which lag time and time to peak correlated with TF cell surface expression.

Association between oncogenic status and risk of venous thromboembolism in patients with non-small cell lung cancer

Background

Preclinical data suggest that oncogene (EGFR and KRAS) events regulate tumor procoagulant activity. However, few studies have prospectively investigated the clinical relevance between the presence of EGFR or KRAS mutations and occurrence of venous thromboembolism(VTE) in patients with non-small cell lung cancer (NSCLC).

Methods

A total of 605 Chinese patients with newly diagnosed NSCLC were included and were followed for a maximum period of 4.5 years. EGFR and KRAS mutations were determined by amplification refractory mutation system polymerase chain reaction method at inclusion. The main outcome was objectively confirmed VTE.

Results

Of the 605 patients, 40.3% (244) had EGFR mutations and 10.2% (62) of patients had KRAS mutations. In multivariable analysis including age, sex, tumor histology, tumor stage, performance status, EGFR and KRAS status, EGFR wild-type (sub-distribution hazard ratio 1.81, 95% confidence interval 1.07–3.07) were associated with the increased risk of VTE. In competing risk analysis, the probability of developing VTE was 8.3% in those with and 13.2% in those without EGFR mutations after 1 year; after 2 years, the corresponding risks were 9.7 and 15.5% (Gray test P = 0.047).

Conclusions

EGFR mutations have a negative association with the risk of VTE in Chinese patients with NSCLC.

Pleiotropic effects of heparins: does anticoagulant treatment increase survival in cancer patients?

The association between venous thromboembolism (VTE) and cancer has been recognized for more than 100 years. Numerous studies have been performed to investigate strategies to decrease VTE incidence and to establish whether treating VTE impacts cancer progression and overall survival. Accordingly, it is important to understand the role of the hemostatic system in tumorigenesis and progression, as there is abundant evidence associating it with cell survival and proliferation, tumor angiogenesis, invasion, and dissemination, and metastasis formation. In attempts to further the scientific evidence, several studies examine survival benefits in cancer patients treated with anticoagulant therapy, specifically treatment with vitamin K antagonists, unfractionated heparin, and low-molecular-weight heparin. Several studies and meta-analyses have been conducted with a special focus on brain tumors. However, no definitive conclusions have been obtained, and more well-designed clinical trials are needed.

Risk factors and prognostic impact of venous thromboembolism in Asian patients with non-small cell lung cancer

Although the overall risk of venous thromboembolism (VTE) is high in patients with non-small cell lung cancer (NSCLC), risk identification is limited. The goal of this study was to estimate the incidence, risk factors and prognostic implications of VTE, and to evaluate a genetic link between oncogenes and the risk of VTE in Asian patients with NSCLC. A total of 1,998 consecutive patients with NSCLC were enrolled and analysed retrospectively. Since the effects of therapeutics on VTE development were modified by stage, stratified analyses were performed. When comparing overall survival in terms of VTE development, a propensity score-matching method was adopted to minimise potential confounding. The six-month and two-year cumulative incidences of VTE were 4.2% and 6.4%, respectively. The risk of VTE increased 2.45-fold with each advancing stage in NSCLC (p<0.001). The independent predictors of VTE were advanced age, pneumonectomy and palliative radiotherapy in localised NSCLC and ineligibility for surgery and palliative radiotherapy in locally advanced NSCLC. Adenocarcinoma histology (vs squamous cell) and former/current smoking status were significant predictors of VTE in metastatic NSCLC. A significant association between VTE and decreased survival was observed only among patients with localised NSCLC. EGFR mutations (p=0.170) and ALK rearrangements (p=0.159) were not associated with VTE development in lung adenocarcinoma. In conclusion, the two-year cumulative incidence of VTE is 6.4% in Asian patient with NSCLC. The significant predictors of VTE are different across stages of NSCLC. The prognostic impact of VTE on poor survival was limited to localised NSCLC.

Cancer and Venous Thromboembolic Disease: A Review

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

Cerebral ischemic events in patients with pancreatic cancer: A retrospective cohort study of 17 patients and a literature review

Stroke is a dramatic complication of pancreatic cancer with mechanisms related to oncological disease. A better description of the characteristics of cerebrovascular events would help better understand the pathogeny and protect vulnerable patients. We thus conducted a descriptive analysis of clinical, biological, and radiological features of patients from our centers and literature.We reviewed consecutive cases of patients who presented cerebrovascular events and pancreatic cancer in 4 stroke units in Lorrain (France) between January 1, 2009 and March 31, 2015, and all reported cases of literature. We identified 17 cases in our centers and 18 reported cases. Fifty-seven per cent of patients were male. Median age was 63 ± 14 years and ranged from 23 to 81 years. All cerebral events were ischemic. At the onset of stroke, pancreatic cancer had already been diagnosed in 59% of the patients in our centers for a mean time of 5.4 months. Five of them (29%) were being treated with gemcitabine and 2 (12%) with folfirinox. Adenocarcinoma at metastatic stage was reported in 82% of cases overall. Brain imaging revealed disseminated infarctions in 64%. High median levels of D-dimer (7600 ± 5 × 10 μg/L), C-reactive protein (63 ± 43 mg/L), and elevated prothrombin time (19 ± 6 seconds) were found. Thirty-six per cent of patients explored with echocardiography were diagnosed with nonbacterial thrombotic endocarditis. Ten of our patients received anticoagulant therapy as secondary stroke prevention without any documented recurrence. Nevertheless, outcome was poor with a median survival time of 28 ± 14 days after stroke onset. Cerebral ischemic events occur at advanced stages of pancreatic cancer, most likely by a thromboembolic mechanism. Disseminated infarctions and high D-dimer, C-reactive protein levels, and a high prothrombin time are the most constant characteristics found in this context. All patients should be screened for nonbacterial thrombotic endocarditis as this etiology supports the use of anticoagulant therapy.

A rare cause of chest pain in a cancer patient

It is well known that cancer and hypercoagulability go hand in hand. Most thromboembolism is venous in nature although arterial thrombosis can occur. Arterial thrombosis secondary to malignancy is usually seen in the lower extremities; however, it can also be seen elsewhere. This is a case of bronchogenic carcinoma with no history of typical atherosclerotic risk factors including smoking, diabetes mellitus, hypertension, or hyperlipidemia presented with chest pain and was found to have an acute ST segment elevation myocardial infection. Coronary angiography showed a large thrombus in the left anterior descending artery in the absence of any atherosclerotic lesions. Malignancy is considered to be the major contributing factor for this myocardial infarction in the absence of both atherosclerotic risk factors and atherosclerotic lesions in the coronary angiography. We will focus on the relationship between cancer and thrombosis with special emphasis on arterial thromboembolism with subsequent development of myocardial infarction.

Pancreatic cancer and thromboembolic disease, 150 years after Trousseau

The connection between pancreatic cancer and venous thrombosis has been discussed for almost 150 years. The exact pathophysiological mechanisms are still partly understood, but it is known that pancreatic cancer induces a prothrombotic and hypercoagulable state and genetic events involved in neoplastic transformation (e.g., KRAS, c-MET, p53), procoagulant factors [e.g., tissue factor (TF), platelet factor 4 (PF4), plasminogen activator inhibitor type 1 (PAI-1)], mucin production (e.g., through activation of P- and L-selectin) and pro-inflammatory factors [e.g., cytokines, cyclooxygenase-2 (COX-2)] may be implicated. Also pancreatitis, both acute and chronic, is associated with increased risk of venous thrombosis, but in this circumstance a direct inflammatory process may be more important. This article discusses the incidence, treatment and outcome of venous thromboembolism (VTE) complicating pancreatic disease, with special emphasis on new knowledge obtained during the last fifteen years.

Management of chemotherapy-induced thromboembolism in breast cancer

Thromboembolic events are common in cancer patients and, apart from contributing to significant morbidity, are regarded as the second leading cause of death in this population. Breast cancer patients are considered low risk for venous thromboembolism; however, the presence of advanced disease and use of chemotherapy and/or other adjunct treatments significantly raises this risk by altering the balance of pro- and anti-coagulant proteins. Low molecular weight heparin is central to the management of venous thromboembolism in this context, whether for prophylaxis, acute management or prevention of recurrences. Risk stratification models need to be incorporated to guide decision making where available.

Thrombin-activatable fibrinolysis inhibitor Thr325Ile polymorphism and plasma level in breast cancer: A pilot study

This study aimed to investigate thrombin-activatable fibrinolysis inhibitor (TAFI) Thr325Ile polymorphism and TAFI antigen (Ag) levels in breast cancer (BC) in the Egyptian population to clarify their role in relation to BC. A group of 300 females was recruited in this study; of these 150 unrelated patients with different stages of BC and 150 age-matched healthy controls. Plasma TAFI Ag was measured by ELISA and TAFI Thr325Ile (rs1926447) polymorphism was genotyped using TaqMan single nucleotide polymorphism (SNP) genotyping assay. The results showed the genotypes of the minor allele; Thr/Ile (CT) and Ile/Ile (TT) were significantly more frequent in patients compared to control group (50.0% and 22.0% vs. 42.0% and 13.3%, respectively) and were also associated with BC susceptibility [OR = 1.9 and 2.6; 95% CI: (1.1–3.3) and (1.3–5.5), respectively P = 0.01]. Ile325 allele carriers were more frequent in cases than in controls (47.0% vs. 34.0%) [OR = 1.7, (95% CI = 1.2–2.4), P = 0.001]. However, TAFI Thr325Ile polymorphism was not associated with BC stage or other clincopathological characteristics. TAFI Ag levels were correlated with advanced stages of BC, poor prognosis and risk of recurrence (P = 0.02, P = 0.04 and P  < 0.001, respectively) and Thr325Ile SNP was significantly correlated with TAFI antigen levels with the C/C genotype corresponding to the highest and the T/T genotype to the lowest TAFI antigen levels (P < 0.001) in the study groups. In conclusion, this study showed for the first time that TAFI Thr325Ile polymorphism could have a contribution to BC susceptibility in our population. Furthermore, high TAFI plasma levels may serve as a predictor of poor prognosis in patients with BC.

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TAFI Thr325Ile polymorphism associated with breast cancer in studied population

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TAFI Thr325Ile polymorphism was significantly correlated with TAFI antigen levels.

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High TAFI antigen levels were correlated with advanced stages of breast cancer.

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High TAFI plasma level could be used to recognize tumor prognosis and risk of recurrence.

Increased coagulation activity and genetic polymorphisms in the F5, F10 and EPCR genes are associated with breast cancer: a case-control study

Background

The procoagulant state in cancer increases the thrombotic risk, but also supports tumor progression. To investigate the molecular mechanisms controlling cancer and hemostasis, we conducted a case-control study of genotypic and phenotypic variables of the tissue factor (TF) pathway of coagulation in breast cancer.

Methods

366 breast cancer patients and 307 controls were genotyped for SNPs (n = 41) in the F2, F3 (TF), F5, F7, F10, TFPI and EPCR genes, and assayed for plasma coagulation markers (thrombin generation, activated protein C (APC) resistance, D-dimer, antithrombin, protein C, protein S, and TF pathway inhibitor (TFPI)). Associations with breast cancer were evaluated using logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (CIs), or the chi-square test.

Results

Four SNPs in F5 (rs12120605, rs6427202, rs9332542 and rs6427199), one in F10 (rs3093261), and one in EPCR (rs2069948) were associated with breast cancer. EPCR rs2069948 was associated with estrogen receptor (ER) and progesterone receptor (PR) positivity, while the SNPs in F5 appeared to follow hormone receptor negative and triple negative patients. The prothrombotic polymorphisms factor V Leiden (rs6025) and prothrombin G20210A (rs1799963) were not associated with breast cancer. High APC resistance was associated with breast cancer in both factor V Leiden non-carriers (OR 6.5, 95% CI 4.1-10.4) and carriers (OR 38.3, 95% CI 6.2-236.6). The thrombin parameters short lag times (OR 5.8, 95% CI 3.7-9.2), short times to peak thrombin (OR 7.1, 95% CI 4.4-11.3), and high thrombin peak (OR 6.1, 95% CI 3.9-9.5) predicted presence of breast cancer, and high D-dimer also associated with breast cancer (OR 2.0, 95% CI 1.3-3.3). Among the coagulation inhibitors, low levels of antithrombin associated with breast cancer (OR 5.7, 95% CI 3.6-9.0). The increased coagulability was not explained by the breast cancer associated SNPs, and was unaffected by ER, PR and triple negative status.

Conclusions

A procoagulant phenotype was found in the breast cancer patients. Novel associations with SNPs in F5, F10 and EPCR to breast cancer susceptibility were demonstrated, and the SNPs in F5 were confined to hormone receptor negative and triple negative patients. The study supports the importance of developing new therapeutic strategies targeting coagulation processes in cancer.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2407-14-845) contains supplementary material, which is available to authorized users.

Absence of tissue factor is characteristic of lymphoid malignancies of both T- and B-cell origin

BACKGROUND

Thrombosis is a marker of poor prognosis in individuals with solid tumors. The expression of tissue factor (TF) on the cell surface membrane of malignant cells is a pivotal molecular link between activation of coagulation, angiogenesis, metastasis, aggressive tumor behavior and poor survival. Interestingly, thrombosis is associated with shortened survival in solid, but not in lymphoid neoplasias.

OBJECTIVES

We sought to study whether the lack of impact of thrombosis on survival in lymphoid neoplasias could be due to a lack of tumor-derived TF expression.

METHODS

We analyzed TF gene (F3) expression in lymphoid (N=114), myeloid (N=49) and solid tumor (N=856) cell lines using the publicly available dataset from the Broad-Novartis Cancer Cell Line Encyclopedia (http://www.broadinstitute.org/ccle/home), and in 90 patient-derived lymphoma samples. TF protein expression was studied by immunohistochemistry (IHC).

RESULTS

In sharp contrast to wide F3 expression in solid tumors (74.2%), F3 was absent in all low and high grade T- and B-cell lymphomas, and in most myeloid tumors, except for select acute myeloid leukemias with monocytic component. IHC confirmed the absence of TF protein in all indolent and high-grade B-cell (0/90) and T-cell (0/20) lymphomas, and acute leukemias (0/11).

CONCLUSIONS

We show that TF in lymphomas does not derive from the malignant cells, since these do not express either F3 or TF protein. Therefore, it is unlikely that thrombosis in patients with lymphoid neoplasms is secondary to tumor-derived tissue factor.

The incidence and predictors of thromboembolic events in patients with lung cancer

Patients with lung cancer experience elevated risk of venous thromboembolism. Cancer patients with thrombosis have a shorter life expectancy and the occurrence of VTE worsens the quality of life and may delay, interrupt, or completely halt the cancer therapy. In a large cohort of lung cancer patients we monitored the incidence of venous thromboembolism and we identified groups of patients with the highest risk of venous thromboembolism suitable for antithrombotic prophylaxis, which could favourably affect their morbidity and mortality.

Pathophysiology and management of thrombosis in cancer: 150 years of progress

The association of thrombosis with cancer has been recognized since the middle of the nineteenth century. It remains a common and serious complication of the cancer itself, as well as chemotherapy. Thrombosis is the second leading cause of death in cancer patients, second only to the cancer itself. For many years the treatment options for managing thrombosis in cancer had been static, but the past decade has seen significant evolution in the management, with the clear superiority of low molecular weight heparin over warfarin for secondary prevention of thrombosis. This article will review the understanding and management of thrombosis in cancer.

Cancer-associated thrombosis: clinical presentation and survival

Background

Thromboembolic events are important causes of morbidity and mortality in cancer patients. Clinical presentation in a community-based setting has not been fully clarified. The purpose of this study was to evaluate the incidence, risk factors, role of thrombophilia, and subsequent survival following thrombosis in cancer patients.

Methods

A retrospective review was undertaken of clinical data for all consecutive patients with histologically confirmed cancer seen by the author at a regional cancer center, with emphasis on cancer-related thrombosis.

Results

Between 2005 and 2012, of 1874 cancer patients, 307 (16.4%) developed thrombosis during their lifetime. Of these patients, 37 (2%) had a history of thrombosis, while the remaining 270 (14.4%) patients developed thrombosis 3 months before or any time after diagnosis of cancer, which was considered to be cancer-related. These patients included 230 (12.3%) with venous thrombosis, 28 (1.5%) cases with arterial occlusion, and 12 (0.6%) with combined venous and arterial thrombosis. Patients of Caucasian ancestry were more prone to develop thrombosis, with a higher frequency of multiple genetic thrombophilia compared with other ethnic groups. In regression analysis, only advanced stages of cancer and the presence of atherosclerosis were predictive of thrombosis. There were no significant differences between venous and arterial thrombosis. The worst survival was noted in patients who developed thrombosis 3 months prior to or shortly after their diagnosis of cancer. There has been a recent improved survival outcome following therapy.

Conclusion

In addition to venous thrombosis, arterial occlusion with stroke and anginal symptoms is relatively common among cancer patients, especially those of Caucasian ancestry, and is possibly related to genetic predisposition.

Prognostic value of the D-dimer test in oesophageal cancer during the perioperative period

BACKGROUND

There has been little research on the perioperative D-dimer levels in oesophageal cancer patients. Plasma D-dimer levels can be used to predict the outcome in cancer patients.

METHODS

A cancer group of 66 oesophageal cancer patients and a control group of 12 patients with benign disease were enrolled in this cohort study. The plasma D-dimer levels during the pre-operation and 3rd and 9th day post-operation periods were prospectively examined and analysed between the two groups. Plasma D-dimer levels were also compared with the clinicopathological characteristics and 3-year survival of the oesophageal cancer patients.

RESULTS

Plasma D-dimer levels increased in both groups after surgery, but they were significantly higher in the cancer group. In oesophageal cancer patients, pre-operation plasma D-dimer levels were significantly higher in TNM stage IV patients. Perioperative plasma D-dimer levels significantly increased after surgery, and the survival was shortened in those patients whose D-dimer levels on the 3rd and 9th post-operative day above the median. In addition, increased plasma D-dimer levels at the 3rd and 9th days after surgery were influenced by the patient's age.

CONCLUSION

In oesophageal cancer patients, D-dimer levels increased after surgery, and the increases were associated with poor outcomes.

Genetic pathways linking hemostasis and cancer

Oncogenic events impact interactions of cancer cells with their surroundings. Amongst the most consequential, in this regard, is the influence on angiogenesis, inflammation and hemostasis. Indeed, mutant oncogenes (EGFR, HER2, RAS, MET, PML-RARα) are known to alter the expression of angiogenic and pro-inflammatory factors, as well as change the cancer cell coagulome, including the levels of tissue factor (TF) and other mediators (PAI-1, COX2). Accompanying losses of tumour suppressor genes (PTEN, p53), and changes in microRNA (miR-19b, miR-520) facilitate these effects. Transforming genes may also trigger ectopic production of coagulation factors (e.g. FVII) by cancer cells and their release and properties of procoagulant microparticles (MPs). By deregulating protease activated receptors (PAR1/2) oncogenes may also change tumour cell responses to coagulation factor signalling. These changes act in concert with microenvironmental factors (hypoxia), stress responses (therapy) and differentiation programs, including epithelial-to-mesechymal transitions (EMT) and through tumour initiating cell (TIC) compartment. In so doing, the coagulation system influences early (initiation, angiogenesis), intermediate (growth, invasion) and late stages (metastasis, relapse) of cancer progression. In fact, TF may act as a molecular switch that controls the transition between dormant, latent and progressive/metastatic disease. TIC-like cells may play a role in these effects, as they express TF and PAR-1/2, and respond to stimulation with their agonists. As major human malignancies (e.g. glioblastoma) are increasingly recognized to consist of a spectrum of molecularly distinct disease subtypes driven by specific genetic pathways, so too may their patterns of interaction differ with the coagulation system. A better understanding of these linkages may be a source of new diagnostic, prognostic and therapeutic opportunities.

Hemostatic factors, innate immunity and malignancy

Genetics-based studies have established the critical importance of tumor cell-associated tissue factor, circulating and endothelial cell-associated regulators of thrombin function and multiple thrombin substrates in metastasis. There appear to be multiple pathways by which procoagulants influence tumor biology, but the capacity of hemostatic factors to regulate innate immune function is at least one emerging theme. Several reports have shown that the platelet/fibrin(ogen) axis supports metastasis by limiting natural killer cellmediated lysis of newly-localized micrometastases. Furthermore, there is increasingly compelling evidence that hemostatic and innate immune system interactions also support very early events in cancer development. Analyses of the role of fibrin(ogen) in inflammation-driven colon cancer established a major role for this provisional matrix protein in early tumor development. A seminal property of fibrin(ogen) driving tumor formation in this context is the capacity to support local leukocyte activation events through engagement of the leukocyte integrin α(M)β(2). More recent studies have also suggested that hemostatic factors can, in at least some settings, program the malignant phenotype in tumor cells. Platelet-derived TGF-β1 and other platelet products were reported to trigger a more invasive and prometastatic epithelial-mesenchymal-like transition in embolic tumor cells. These findings support the intriguing concept that tumor cell functional properties can continue to evolve, even beyond the primary tumor site, in response to tumor cell-hemostatic factor interactions in the bloodstream. Taken together, there is strong evidence that the hemostatic system plays a multifaceted role in cancer pathogenesis and that therapies targeting selected hemostatic factors may present a powerful means to impede tumor development and metastasis.

[Thromboembolic events in malignant diseases]

There is a bidirectional connection between tumors and thrombosis. On one hand, thromboembolic events are more frequent in cases of malignancies, on the other hand, proliferation of tumor cells, progression of the malignant process and metastasis formation are facilitated by the activation of the hemostatic system. Thromboembolic events are associated with a worse prognosis in case of patients with malignant diseases. Thromboembolism is the second most frequent cause of death in patients with malignant tumors. Mortality is twice as high in patients with thromboembolism compared to those without it. The incidence of thromboembolism shows an increasing tendency. There has been a 28% increase among hospitalized cancer patients between 1995 and 2003. One reason is that the new anti-tumor agents have more pronounced prothrombotic activity than those of traditional chemotherapeutic drugs. Assessment of the thrombotic risk of cancer patients becomes more important. Several guidelines have been published concerning the prevention and treatment of thromboembolism in patients with malignancy. The risk of thrombosis is influenced not only by the type of malignancy but there are also large individual differences. Furthermore, the risk of thrombosis changes during the disease process in the same patient. Perioperative thromboprophylaxis is a very important issue considering oncologic surgery. Thromboprophylaxis of oncologic patients has a high significance in respect of morbidity and mortality. However, thromboprophylaxis may also cause serious complications thus the correct risk assessment of cancer patients is very important.

Thrombosis in multiple myeloma (MM)

Thrombosis is a frequent feature in individuals with myeloma, particularly those treated with oral immunomodulatory drugs (IMID) such as thalidomide or lenalidomide concomitantly with anthracyclines or dexamethasone. Up to a third of these individuals may develop venous thrombosis if not given the benefit of prophylaxis. Interestingly, in contrast to individuals with solid tumors in whom thrombosis is a marker of poor prognosis, thrombosis does not impact overall survival in patients with myeloma. This finding suggests that the mechanisms of thrombosis in hematological neoplasms may differ from solid epithelial tumors and that thrombosis in the former may be driven by therapy and not by a procoagulant phenotype of the neoplastic plasma cells. This may also explain why thrombosis in the context of IMID-based therapy may be prevented by the use of prophylactic aspirin. In this text, we review the pathogenesis of thrombosis in myeloma, its relation to different chemotherapeutic regimens and the use of thrombo-prophylaxis.

Clinical analysis of postoperative venous thromboembolism risk factors in lung cancer patients

BACKGROUND AND OBJECTIVES

The objective of this study is to explore clinical risk factors for venous thromboembolism (VTE) in postoperative lung cancer patients in order to provide a basis for the prevention and treatment of postoperative VTE.

METHODS

A total of 1,001 lung cancer patients were retrospectively analyzed. Each patient was confirmed with surgical pathology diagnosis and had a complete clinical and follow-up record. VTE was identified in a combination of spiral computed tomography (CT), pulmonary angiography, and color Doppler ultrasound. We used life table method to create an occurrence frequency curve of thrombosis. We also searched for high risk factors for postoperative VTE with Cox multivariate regression model and created frequency curves of thrombosis against different risk factors using Kaplan-Meier method.

RESULTS

As of July 31, 2011, the median follow-up time is 25.73 ± 0.11 months (19.23-31.37). The cumulative frequency of VTE among 1,001 lung cancer patients is 2%, 3%, 4%, 5%, and 5.3% over 1, 3, 6, 12, and 30 months after the surgery. COX regression analysis showed that the hazard ratio of VTE occurrence in patients with incomplete resection relative to ones with complete resection is 9.867 (95% CI: 5.275-18.459, P = 0.000). And the hazard ratio of VTE occurrence is 3.472 (95% CI: 1.761-6.845, P = 0.000) in patients with anti-angiogenesis treatment compared to patients without such treatment. The hazard ratio of VTE occurrence is 2.808 (95% CI: 1.439-5.479, P = 0.002) in patients with EGFR-TKI treatment relative to patients without the treatment, and 7.520 (95% CI: 3.968-14.250, P = 0.000) in patients with an increase in D-dimer level relative to normal ones

CONCLUSIONS

The highest incidence of VTE is within 1 month after lung cancer surgery. High risk factors for VTE include incomplete surgical resection, postoperative use of anti-angiogenesis drugs, EGFR-TKI application and an increase in preoperative D-dimer level.

Preventing venous thromboembolism in hospitalized patients with cancer: improving compliance with clinical practice guidelines

PURPOSE

The use of anticoagulants for the prevention of venous thromboembolism (VTE) in hospitalized medical and surgical oncology patients is discussed.

SUMMARY

Hospitalized patients are often at risk for developing VTE, and risk is increased in patients who have cancer. Moreover, the incidence of VTE appears to be rising in hospitalized cancer patients, who have a 2.2-fold increased risk of mortality with a VTE compared with similar patients without VTE. The literature indicates that these patients are often inadequately anticoagulated, despite strong recommendations for prophylaxis. Although there are few studies that specifically address VTE prophylaxis in cancer patients, there are several large trials that have examined data in cancer subgroups. The trials have directly compared low-molecular-weight heparin (LMWH) with placebo, unfractionated heparin with LMWH, factor Xa inhibitor (fondaparinux) with placebo, and fondaparinux with LMWH. Three important guidelines provide current recommendations for VTE prophylaxis; the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the American College of Chest Physicians (ACCP) recommend unfractionated heparin, LMWH, or fondaparinux for VTE prophylaxis when there are no contraindications. Pharmacists can play an essential role in ensuring that VTE prophylaxis is appropriate for individual patients. Interventions to improve compliance with guidelines are particularly important now due to financial incentives from quality-focused organizations whose mandate is to decrease preventable mortality events in hospitals.

CONCLUSION

Hospitalized patients with cancer often do not receive appropriate thromboprophylaxis. Guidelines from ASCO, ACCP, and NCCN recommend unfractionated heparin, an LMWH, or fondaparinux for VTE prophylaxis when there are no contraindications to such therapy.

Absence of tissue factor expression by neoplastic plasma cells in multiple myeloma

Thrombosis portends a poor prognosis in individuals with solid tumors. Constitutive expression of tissue factor (TF) by cancer cells is a key in triggering activation of coagulation and promoting aggressive tumor behavior. Though multiple myeloma (MM) is associated with a high frequency of thrombosis in the context of thalidomide and lenalidomide therapy, prognosis is not affected by its occurrence. We sought to determine the expression of TF in MM. F3 (TF gene) expression profiling was analyzed in 55 human MM cell lines (HMCL) and in 223 solid tumor cell lines obtained from GlaxoSmithKline (GSK) Cancer Cell Line Genomic Profiling Dataset. TF was not expressed in any of the 55 HMCLs studied, in sharp contrast to solid tumors, 90% of which showed TF expression. F3 expression was also absent in tumor samples from 239 MM patients. Immunohistochemistry for TF was negative, with either no or focal (1+) staining in 70/73 MM patients. Only three marrow biopsies were moderately (2+) positive either focally or diffusely, suggesting that in rare cases bone marrow microenvironment may support TF expression. General lack of TF expression by neoplastic plasma cells may explain why thrombosis is not predictive of poor outcome, and why aspirin prophylaxis is often effective in MM.

Targeting the MET oncogene in cancer and metastases

IMPORTANCE OF THE FIELD

'Invasive growth' is a genetic program involved in embryonic development and adult organ regeneration and usurped by cancer cells. Although its control is complex, tumor- and context-specific and regulated by several cytokines and growth factors, the role played by the MET oncogene is well documented. In human cancers the contribution of MET to invasive growth is mainly through overexpression, driven by unfavorable microenvironmental conditions. MET activation confers a selective advantage to neoplastic cells in tumor progression and drug resistance. A subset of tumors feature alterations of the MET gene and a consequent MET-addicted phenotype.

AREAS COVERED IN THIS REVIEW

The molecular basis and rationale of MET inhibition in cancer and metastases are discussed. A number of molecules designed to block MET signaling are under development and several Phase II trials are ongoing.

WHAT THE READER WILL GAIN

Knowledge of the state of the art of anti-MET targeted approaches and the molecular basis and strategies to select patients eligible for treatment with MET inhibitors.

TAKE HOME MESSAGE

Due to its versatile functions MET is a promising candidate for cancer therapy. Understanding molecular mechanisms of sensitization and resistance to MET inhibitors is a priority to guide tailored therapies and select patients that are most likely to achieve a clinical benefit.

Acute saddle pulmonary embolism in Ewing sarcoma

Two young adults had similar presentations of Ewing sarcoma, with spinal cord involvement and significant neurologic deficits. Shortly after workup, stabilization, and initiation of chemotherapy, both developed acute saddle pulmonary embolism, despite prophylactic anticoagulation. In both cases, prompt intravenous thrombolysis and therapeutic anticoagulation successfully managed this complication. Review of the presentation, treatment options, and most current guidelines for acute saddle pulmonary embolism follow the case presentations.