Pancreatic carcinoma, thrombosis and mean platelet volume: single center experience from the southeast region of Turkey

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.

Incidence, risk factors and the prognostic role of thromboembolic events (TEEs) amongst patients with metastatic pancreatic adenocarcinoma (PAAD): a retrospective, single-center analysis

Background

Thromboembolic events (TEEs) are frequent among patients with pancreatic adenocarcinoma (PAAD). We set out to estimate the incidence and establish predictive risk factors for TEE and estimate the impact of TEEs on the overall survival (OS) of patients with metastatic PAAD.

Methods

This is a retrospective, single-center study. We included patients with a pathologically confirmed diagnosis of PAAD with distant metastases treated at AC Camargo Cancer Center from 2016 to 2021. We used the competitive risk survival models to estimate the cumulative incidence of TEE. Risk factors for the development of TEEs were evaluated using the competitive risk and logistic regression models. The impact of TEEs on OS was assessed using both landmark and time-dependent covariate Cox survival analyses.

Results

The study population consists of 199 patients. The cumulative incidence of TEEs in 1, 6 and 24 months were 10.1%, 19.3% and 30.2%, respectively. Log10(CA 19-9) was the only factor independently associated with increased risk of TEEs in the logistic regression (Odds ratio = 1.03; 95% confidence interval (95%CI), 1.00-1.06; p = 0.030) and competitive risk survival (Subdistribution hazard ratio = 1.14; 95%CI, 1.02-1.27; p = 0.019) models. In the landmark analysis, early TEEs (within 1 month of diagnosis) were not associated with inferior OS. In the time-dependent covariate Cox proportional hazard model, TEEs were not found to be statistically associated with inferior OS, although there was a trend towards it (Hazard ratio = 1.59; 95%CI, 0.99-2.54; p = 0.051).

Conclusion

TEEs occur in a large fraction of patients with metastatic PAAD. Statistical models with higher predictive performance are currently needed. For the time being, consideration for prophylactic anticoagulation should be done on an individual basis.

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

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

Incidence, timing and risk factors of venous thromboembolic events in patients with pancreatic cancer

INTRODUCTION

Pancreatic cancer is associated with a high risk of venous thromboembolism (VTE). However, comprehensive data on incidence, timing and relevant determinants of VTE in this particular population are scarce. Current study assesses incidence, timing and predictors of VTE in pancreatic cancer through different phases of disease.

METHODS

All pancreatic cancer patients treated in our tertiary referral center between 2013 through 2017 were studied. Occurrence of VTE was evaluated from diagnosis through end of follow-up or death. Relevant determinants of VTE were identified in logistic regression models. Hazard ratios were calculated to evaluate impact of VTE on overall survival.

RESULTS

In total, 361 patients were followed for a median period of 43 months; 64 were diagnosed with VTE (18%). Most were tumor related thrombosis (59%), incidental (75%) and occurred after anti-cancer treatment had been stopped (80%), only 1.6% occurred during remission phase. Stage IV pancreatic cancer was a predictor for VTE (hazard ratio (HR) 2.46, 95% confidence interval (CI) 0.9-6.8). Biliary drainage (HR 0.52, 95%CI 0.28-0.98) and tumor resection (HR 0.45, 95%CI 0.45-1.83) were protective factors. VTE was not associated with worse survival (HR 1.3; 95% CI 0.97-1.74).

CONCLUSIONS

VTE in pancreatic cancer is disease-stage dependent, with 80% occurring in advanced phases of disease when patients no longer receive active treatment. We speculate that this is the main reason for the absence of a survival effect of VTE in our cohort. These practice-based findings should be taken into account when considering wide-spread introduction of primary thromboprophylaxis in patients with pancreatic cancer.

The Role of Hematological Inflammatory Biomarkers in the Diagnosis of Lung Cancer and in Predicting TNM Stage

OBJECTIVE

The aim of study is to investigate whether hematological inflammatory biomarkers could be useful to detect patients with lung cancer.

METHODS

The contribution of hematological biomarkers to the diagnosis of lung cancer and prediction of TNM was examined.

RESULTS

NLR, PLR, MPV values were found to be higher in patients with lung cancer (all p < .001). NLR and PLR were found to be high, MPV was found to be lower in disease of advanced stage (p < .001).

CONCLUSIONS

This study found that NLR, PLR and MPV values were significantly higher in patients with lung cancer.

Burden of venous thromboembolism in patients with pancreatic cancer

Pancreatic cancer (PC) is a devastating malignancy with fewer than 10% of patients being alive at 5 years after diagnosis. Venous thromboembolism (VTE) occurs in approximatively 20% of patients with PC, resulting in increased morbidity, mortality and significant health care costs. The management of VTE is particularly challenging in these frail patients. Adequate selection of the most appropriate anticoagulant for each individual patient according to the current international guidelines is warranted for overcoming treatment challenges. The International Initiative on Thrombosis and Cancer multi-language web-based mobile application (downloadable for free at www.itaccme.com) has been developed to help clinicians in decision making in the most complex situations. In this narrative review, we will discuss the contemporary epidemiology and burden of VTE in PC patients, the performances and limitations of current risk assessment models to predict the risk of VTE, as well as evidence from recent clinical trials for the primary prophylaxis and treatment of cancer-associated VTE that support up-dated clinical practice guidelines.

Primary Thromboprophylaxis in Ambulatory Pancreatic Cancer Patients Receiving Chemotherapy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Patients with pancreatic cancer (PC) carry the highest risk of venous thromboembolism (VTE) amongst all cancer patients. Appropriate use of primary thromboprophylaxis might significantly and safely reduce its burden. We performed a systematic review of published studies and meeting abstracts using MEDLINE and EMBASE through July 2020 to evaluate the efficacy and safety of primary thromboprophylaxis in ambulatory PC patients receiving chemotherapy. The Mantel–Haenszel random effect model was used to estimate the pooled event-based risk ratio (RR) and the pooled absolute risk difference (RD) with a 95% confidence interval (CI). Five randomized controlled studies with 1003 PC patients were included in this meta-analysis. Compared to placebo, thromboprophylaxis significantly decreased the risk of VTE (pooled RR 0.31, 95% CI 0.19–0.51, p < 0.00001, I² = 8%; absolute RD −0.08, 95% CI −0.12–−0.05, p < 0.00001, I² = 0%), with an estimated number needed to treat of 11.9 patients to prevent one VTE event. Similar reductions of VTE were observed in studies with parenteral (RR 0.30, 95% CI 0.17–0.53) versus oral anticoagulants (RR 0.37, 95% CI 0.14–0.99) and in studies using prophylactic doses of anticoagulants (RR 0.34, 95% CI 0.17–0.70) versus supra-prophylactic doses of anticoagulants (RR 0.27, 95% CI 0.08–0.90). The pooled RR for major bleeding was 1.08 (95% CI 0.47–2.52, p = 0.85, I² = 0%) and the absolute RD was 0.00 (95% CI −0.02–0.03, p = 0.85, I² = 0%). Evidence supports a net clinical benefit of thromboprophylaxis in ambulatory PC patients receiving chemotherapy. Adequately powered randomized phase III studies assessing the most effective anticoagulant and the optimal dose, schedule and duration of thromboprophylaxis to be used are warranted.

Primary Thromboprophylaxis in Pancreatic Cancer Patients: Why Clinical Practice Guidelines Should Be Implemented

Exocrine pancreatic ductal adenocarcinoma, simply referred to as pancreatic cancer (PC) has the worst prognosis of any malignancy. Despite recent advances in the use of adjuvant chemotherapy in PC, the prognosis remains poor, with fewer than 8% of patients being alive at 5 years after diagnosis. The prevalence of PC has steadily increased over the past decades, and it is projected to become the second-leading cause of cancer-related death by 2030. In this context, optimizing and integrating supportive care is important to improve quality of life and survival. Venous thromboembolism (VTE) is a common but preventable complication in PC patients. VTE occurs in one out of five PC patients and is associated with significantly reduced progression-free survival and overall survival. The appropriate use of primary thromboprophylaxis can drastically and safely reduce the rates of VTE in PC patients as shown from subgroup analysis of non-PC targeted placebo-controlled randomized trials of cancer patients and from two dedicated controlled randomized trials in locally advanced PC patients receiving chemotherapy. Therefore, primary thromboprophylaxis with a Grade 1B evidence level is recommended in locally advanced PC patients receiving chemotherapy by the International Initiative on Cancer and Thrombosis clinical practice guidelines since 2013. However, its use and potential significant clinical benefit continues to be underrecognized worldwide. This narrative review aims to summarize the main recent advances in the field including on the use of individualized risk assessment models to stratify the risk of VTE in each patient with individual available treatment options.

Large platelet size is associated with poor outcome in patients with metastatic pancreatic cancer

Background Platelets are a major cellular component of blood and their interaction with cancer cells is well-established to influence cancer progression and metastases. The physical size of platelets may have a critical impact on the interaction with cancer cells. In this study, we explored the potential prognostic role of platelet size measured by the determination of the mean platetlet volume (MPV) in patients with pancreatic ductal adenocarcinoma (PDAC). Methods Data from 527 patients with PDAC diagnosed and treated between 2004 and 2015 at a single center were evaluated retrospectively. Associations between MPV and baseline covariates were assessed with Wilcoxon's rank-sum tests, χ2-tests, and Fisher's exact tests. Median follow-up was estimated with a reverse Kaplan-Meier estimator according to Schemper and Smith. Analysis of time-to-death was performed with Kaplan-Meier estimators, log-rank tests and uni- and multivariable Cox proportional hazards models. Results The median MPV was 10.5 femto liter (fL) [9.8-11.3], ranged from 5.9 to 17.7 fL. A large platelet volume was associated with high-grade G3/4 tumors (p=0.004) and worse overall survival (OS) in patients with metastatic disease in univariable analysis (hazard ratio [HR] per fL increase in MPV=1.13 [95% CI: 1.04-1.23, p=0.005]). In multivariable analysis of metatatic PDAC patients, the adverse association between large platelets and a higher risk-of-death prevailed (adjusted HR per doubling of MPV=2.00; 95% CI: 1.10-3.62, p=0.02). Conclusions Large platelets represent a negative prognostic factor and add an independent prognostic information to well-established factors in PDAC patients. MPV should be considered for future individual risk assessment in patients with stage IV PDAC.

Comparison of Platelet Distribution Width and CA19-9 in Resectable Pancreas Cancer

Background

Platelets are considered an important source of prothrombotic agents associated with inflammation in cancer related diseases. We aimed to compare the diagnostic accuracy of the platelet distribution width (PDW) and CA19-9 in resectable pancreas cancer.

Method

A total of 83 stage-1 and 2 pancreatic adenocarcinoma (PAC) patients, and 85 age and sex-matched healthy participants were included in the study. All preoperative patient data, including PDW and CA19-9 were analyzed in terms of sensitivity, specificity, positive and negative predictive values, likelihood ratios, and diagnostic accuracy.

Results

Demographic features were not significantly different among the groups. Platelet distribution width and CA19-9 were significantly higher in PAC compared to control group (p= 0.0001). Diagnostically, the sensitivity and specificity were 79% and 85% for PDW, while 78% and 91% for CA19-9. Diagnostic accuracy was measured by the area under the ROC curve, and PDW differs significantly (p<0.001), with a value of 0.874 (95% CI: 0.804-0.929).

Conclusion

Platelet distribution width indicated similar sensitivity and specificity with CA19-9 in patients with resectable PAC. This result strongly advice that PDW, which has more routine option and cost-effectivity than CA19-9, can be used for diagnosis of resectable PAC as a strong alternative.

[Venous thromboembolism and pancreatic cancer]

Pancreatic cancer (PC) is a devastating malignancy with an overall 5-year survival of 8% for all stages combined. Most of the PC patients diagnosed have an advanced disease (40%) or metastatic stage (40%), which eliminates surgery as a potentially curative treatment. The disease course is often complicated by venous thromboembolism (VTE) events, which per se account for significant morbidity and mortality, with significantly worsen survival. PC is associated with the highest risk of VTE among all cancer patients. We review the literature data to address the incidence and clinical outcomes of VTE in PC patients. VTE incidence varies from 5 to 41% according to epidemiological studies and is as high as 57% in postmortem series. Since 2013, international clinical practice guidelines recommend primary thromboprophylaxis with a grade 1B level of evidence as an adjuvant therapy in advanced PC. A recent meta-analysis of randomized controlled trials investigating the benefit and risk of low-molecular-weight heparins (LMWH) in ambulatory advanced PC patients under chemotherapy showed that the incidence of VTE was 2.1% in patients treated with LMWH and 11.2% in controls (risk ratio, 0.18; 95% CI, 0.083-0.39; P<0.0001). In conclusion, improved earlier diagnosis and effective management of VTE, a frequent and life-threatening complication in PC, is warranted to improve PC patient outcomes.

Visceral Thromboses in Pancreas Adenocarcinoma: Systematic Review

Within gastrointestinal malignancies, primary hepatocellular carcinoma and pancreatic ductal adenocarcinoma (PDAC) are frequently associated with visceral thromboses (VT). Thrombus formation in the portal (PVT), mesenteric (MVT), or splenic vein (SVT) system leads to portal hypertension and intestinal ischemia. VT in PDAC may convey a risk of increased distal thrombosis and poses therapeutic uncertainty regarding the role of anticoagulation. An increasing number of reports describe VT associated with PDAC. It is possible that early diagnosis of these events may help reduce morbidity and speculatively improve oncologic outcomes. To perform a systematic review to study PVT, MVT, and SVT associated with PDAC, and to provide a comprehensive review. Medline/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library. Data Extraction and Assessment: Two blinded independent observers extracted and assessed the studies for diagnosis of PVT, MVT, and SVT in PDAC. Studies were restricted to English-language literature published between 2007 and 2016. Eleven articles were identified. Five case reports and 7 retrospective studies were found, with a total of 127 patients meeting the inclusion criteria. The mean age at diagnosis was 64 years. PVT was found in 35% (n = 46), SVT in 52% (n = 65), and MVT in 13% (n = 15). Mean follow-up time was 26 months. Only 3 of the selected articles studied the impact of anticoagulation in VT. All patients with nonvisceral thrombosis (eg, deep-vein thrombosis, pulmonary emboli) were therapeutically treated; in contrast, patients with VT only rarely received treatment. VT in PDAC is a frequent finding at diagnosis or during disease progression. Evidence to guide treatment choices is limited, and current management is based on inferred experience from nononcologic settings. Anticoagulation appears to be safe in VT, with most of the large studies recommending a careful assessment for patients at a high risk of bleeding.

Thromboembolisms in Advanced Pancreatic Cancer: A Retrospective Analysis of 475 Patients

OBJECTIVES

Pancreatic cancer is reported to be highly associated with thromboembolism (TE). The aim of this analysis is to clarify risk factors for TE and its clinical impact in Japanese patients with pancreatic cancer.

METHODS

Data on consecutive pancreatic cancer patients receiving systemic chemotherapy between August 1999 and July 2015 were retrospectively studied. Both symptomatic and asymptomatic, arterial and venous TEs were included in the analysis. Risk factors for TE development were analyzed using a proportional hazards model with death without TE as a competing risk. The impact of TE on survival was also evaluated using a time-dependent covariate multiple Cox model.

RESULTS

A total of 475 patients were included in the analysis, and 57 TEs (12%) were identified: 45 venous TEs and 12 arterial TEs. The median time to TE was 169 days and the median survival from TE was 65 days. Liver metastasis was the only significant risk factor for TE (subdistribution hazards ratio, 2.15; P = 0.01), and TE was significantly associated with poor prognosis (hazards ratio, 3.31; P < 0.01).

CONCLUSIONS

Thromboembolism was not uncommon in Japanese patients receiving chemotherapy for advanced pancreatic cancer and was associated with poor prognosis. Liver metastasis was the risk factor for TE.

Role of increased mean platelet volume (MPV) and decreased MPV/platelet count ratio as poor prognostic factors in lung cancer

OBJECTIVES

In this study, they investigated whether mean thrombocyte volume (MPV) and MPV/platelet count ratio have a prognostic significance in advanced NSCLC or not.

METHODS

A total of 496 NSCLC patients at stage IIIB/IV and did not meet exclusion criteria were included in the study. The demographic features (age, gender, smoking habit), clinical characteristics (performance status, weight loss, disease stage, first-line treatment regimen), laboratory tests (levels of hemoglobin, lactate dehydrogenase and calcium as well as MPV, MPV/platelet count ratio and counts of white blood cell, platelet), and histological features (histologic type, tumor grade) were recorded.

RESULTS

The MPV levels of all patients were determined as 10.2 {plus minus} 3.4 (range, 6.4-14.1 fL). With ROC curve analysis, the MPV/PC ratio was associated with a sensitivity of 67.8% and a specificity of 84.8% at a cutoff value of 0.47424 for presence of brain metastasis at the time of diagnosis. Univariate analysis showed that OS was significantly shorter in the group with an increased MPV level than in the other group (median OS time 6.8 months vs. 11.5 months, log-rank, P = .032). Multivariate analysis confirmed that an increased MPV level was an independent poor prognostic factor for OS (HR: 1.704, 95% CI: 1.274-3.415, P = .014).

CONCLUSIONS

Unlike results of previous studies, the study showed that increased MPV was an important prognostic factor in patients with NSCLC. Hence, an increased MPV level may be used as a prognostic biomarker to estimate for poor overall survival in patients with NSCLC.

Increased UGT1A3 and UGT1A7 expression is associated with pancreatic cancer

UGT1A play important roles in the glucuronidation of a variety of endogenous and exogenous compounds. UGT1A isoforms are expressed tissue specifically. The aim of this study was to examine the relationship between UGT1A3 and UGT1A7 mRNA expression and pancreatic cancer. Paired healthy and tumor tissue samples of 43 patients with pancreatic cancer were included in this study. UGT1A3 and UGT1A7 mRNA expressions were analyzed by real time-PCR. In the result of study, UGT1A3 and UGT1A7 mRNA expressions were significantly higher in tumor tissue than normal tissue of pancreatic cancer patients (p<0.05). In addition, high mRNA expression of UGT1A3 and UGT1A7 was significantly associated with larger tumor size (p<0.05). The data suggested that UGT1A3 and UGT1A7 may play roles in the progression of pancreatic cancer. Consequently, UGT1A3 and UGT1A7 are potential prognostic indicators.

Relationships between C-kit expression and mean platelet volume in benign, preneoplastic and neoplastic endometrium

BACKGROUND

c-Kit is a proto-oncogene that encodes a tyrosine kinase receptor (CD117). Mean platelet volume (MPV) is a useful marker for demonstrating thrombocyte function. We aimed to investigate whether c-kit is expressed in benign, preneoplastic and neoplastic endometrial tissues and whether MPV has a relation with c-kit expression and its intensity.

MATERIALS AND METHODS

c-Kit expression was investigated immunohistochemically in 10 samples of normal endometrium (n=10), simple endometrial hyperplasia (5 cases with atypia and 10 cases without atypia), complex endometrial hyperplasia (10 cases with atypia and 10 cases without atypia) and endometrial cancer (EC) (10 cases grade I and 10 cases grade II) and MPV of all cases was checked.

RESULTS

c-Kit expression was observed at very low rates in cases with normal endometrial tissues (NE) and in hyperplasia without atypia. c-Kit expression and immunostaining were strong in endometrial atypia and EC. MPV levels of complex atypical endometrial hyperplasia (CAEH) (p:0.002), EC grade I (ECG I) (p<0.001) and EC grade II (ECG II) (p<0.001) were significantly elevated when compared with the NE group. Both c-kit expression and intensity of immunostaining had a positive correlation with MPV level.

CONCLUSIONS

While c-kit expression and intensity of immunostaining were mildly positive in NE and hyperplasia without atypia, they were clearly observed in EC and hyperplasia with atypia. As c-kit expression is related to the mutagenesis a long-term follow- up may be needed in these cases. A high MPV level may be a good test for demonstrating c-kit expression and intensity of immunostaining.