Inherited thrombophilia gene mutations and risk of venous thromboembolism in patients with cancer: A systematic review and meta-analysis

In the general population, individuals with an inherited thrombophilia have a higher risk of thrombosis, but the effect of inherited thrombophilia on the risk of cancer-associated venous thromboembolism (VTE) remains controversial. Our objective was to determine the risk of VTE in cancer patients with inherited thrombophilia. We conducted a systematic review and meta-analysis of studies reporting on VTE after a cancer diagnosis in adult patients who were tested for inherited thrombophilia. In September 2022, we searched Medline, EMBASE, and Cochrane Central. Two reviewers screened the abstracts/full texts and assessed study quality using the Quality in Prognostic Studies tool. We used Mantel-Haenszel random-effects models to estimate pooled odds ratios (OR) of VTE and 95% confidence intervals (95%CI). We included 37 and 28 studies in the systematic review and meta-analysis, respectively. Most studies focused on specific cancer types and hematologic malignancies were rare. The risk of VTE was significantly higher in cancer patients with non-O (compared with O) blood types (OR: 1.56 [95% CI: 1.28-1.90]), Factor V Leiden, and Prothrombin Factor II G20210A mutations compared with wild types (OR: 2.28 [95% CI: 1.51-3.48] and 2.14 [95% CI: 1.14-4.03], respectively). Additionally, heterozygous and homozygous methylenetetrahydrofolate reductase C677T had ORs of 1.50 (95% CI: 1.00-2.24) and 1.38 (95% CI: 0.87-2.22), respectively. Among those with Plasminogen-Activator Inhibitor-1 4G/5G, Vascular Endothelial Growth Factor (VEGF) A C634G, and VEGF C2578A mutations, there was no significant association with VTE. In conclusion, this meta-analysis provided evidence that non-O blood types, Factor V Leiden, and Prothrombin Factor II G20210A mutations are important genetic risk factors for VTE in cancer patients.

Cellular Components Contributing to the Development of Venous Thrombosis in Patients with Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive type of cancer and has a poor prognosis. Patients with PDAC are at high risk of developing thromboembolic events, which is a leading cause of morbidity and mortality following cancer progression. Plasma-derived coagulation is the most studied process in cancer-associated thrombosis. Other blood components, such as platelets, red blood cells, and white blood cells, have been gaining less attention. This narrative review addresses the literature on the role of cellular components in the development of venous thromboembolism (VTE) in patients with PDAC. Blood cells seem to play an important role in the development of VTE. Altered blood cell counts, i.e., leukocytosis, thrombocytosis, and anemia, have been found to associate with VTE risk. Tumor-related activation of leukocytes leads to the release of tissue factor-expressing microvesicles and the formation of neutrophil extracellular traps, initiating coagulation and forming a scaffold for thrombi. Tissue factor-expressing microvesicles are also thought to be released by PDAC cells. PDAC cells have been shown to stimulate platelet activation and aggregation, proposedly via the secretion of podoplanin and mucins. Hypofibrinolysis, partially explained by increased plasminogen activator inhibitor-1 activity, is observed in PDAC. In short, PDAC-associated hypercoagulability is a complex and multifactorial process. A better understanding of cellular contributions to hypercoagulability might lead to the improvement of diagnostic tests to identify PDAC patients at highest risk of VTE.

Enhanced Recovery after Surgery (ERAS) in Postoperative Lung Cancer Patients: A Novel Perioperative Strategy for Preventing Venous Thromboembolism and Improving Quality of Life

This study aimed to assess the impact of enhanced recovery after surgery (ERAS) intervention in preventing venous thromboembolism (VTE) among postoperative lung cancer patients. Conducted from January 2022 to January 2023, the research involved 125 lung cancer patients randomly assigned to either a control group (n = 60) receiving routine care, or an ERAS group (n = 65) which received both routine care and ERAS interventions. The ERAS program comprised a comprehensive series of interventions meticulously implemented throughout the preoperative, intraoperative, and postoperative phases. Thrombotic risk assessment using the Caprini Risk Assessment Model (RAM) was conducted preoperatively and on postoperative day 5 (POD 5), with plasma D-dimer levels measured preoperatively, on POD 1, POD 3, and POD 5. Quality of life and patient satisfaction were assessed at discharge using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Lung Cancer Module 13 (QLQ-LC13) and The Newcastle Satisfaction with Nursing Scale (NSNS), respectively. The ERAS group demonstrated significantly lower Caprini RAM scores on POD 5 compared to the control group, with lower D-dimer levels on POD 3 and POD 5. The incidence of VTE was lower in the ERAS group (1.54%) compared to the control group (11.67%) during hospitalization. At discharge, the ERAS group showed improved quality of life, with higher satisfaction scores for nursing care and their hospital stay. ERAS nursing interventions effectively mitigate thrombotic risk, improve D-dimer levels, enhance postoperative quality of life, and elevate patient satisfaction among individuals undergoing lung cancer surgery.

Utility of plasma D-dimer for diagnosis of venous thromboembolism after hepatectomy

BACKGROUND

Venous thromboembolism (VTE) is a potentially fatal complication of hepatectomy. The use of postoperative prophylactic anticoagulation in patients who have undergone hepatectomy is controversial because of the risk of postoperative bleeding. Therefore, we hypothesized that monitoring plasma D-dimer could be useful in the early diagnosis of VTE after hepatectomy.

AIM

To evaluate the utility of monitoring plasma D-dimer levels in the early diagnosis of VTE after hepatectomy.

METHODS

The medical records of patients who underwent hepatectomy at our institution between January 2017 and December 2020 were retrospectively analyzed. Patients were divided into two groups according to whether or not they developed VTE after hepatectomy, as diagnosed by contrast-enhanced computed tomography and/or ultrasonography of the lower extremities. Clinicopathological factors, including demographic data and perioperative D-dimer values, were compared between the two groups. Receiver operating characteristic curve analysis was performed to determine the D-dimer cutoff value. Univariate and multivariate analyses were performed using logistic regression analysis to identify significant predictors.

RESULTS

In total, 234 patients who underwent hepatectomy were, of whom (5.6%) were diagnosed with VTE following hepatectomy. A comparison between the two groups showed significant differences in operative time (529 vs 403 min, P = 0.0274) and blood loss (530 vs 138 mL, P = 0.0067). The D-dimer levels on postoperative days (POD) 1, 3, 5, 7 were significantly higher in the VTE group than in the non-VTE group. In the multivariate analysis, intraoperative blood loss of > 275 mL [odds ratio (OR) = 5.32, 95% confidence interval (CI): 1.05-27.0, P = 0.044] and plasma D-dimer levels on POD 5 ≥ 21 μg/mL (OR = 10.1, 95%CI: 2.04-50.1, P = 0.0046) were independent risk factors for VTE after hepatectomy.

CONCLUSION

Monitoring of plasma D-dimer levels after hepatectomy is useful for early diagnosis of VTE and may avoid routine prophylactic anticoagulation in the postoperative period.

Reinfusion of peritoneal fluid elevates the level of plasma D-dimer in patients with early-onset ovarian hyperstimulation syndrome

Purpose

This study aimed to elucidate the factors that affect the dynamics of blood D-dimer in ovarian hyperstimulation syndrome (OHSS).

Methods

We retrospectively reviewed medical records from two hospitals and extracted data obtained during assisted reproductive technology and OHSS treatment. Blood D-dimer levels during hospitalization were plotted against body weight. Other factors possibly related to blood D-dimer levels were also analyzed.

Results

The analysis included 10 patients with OHSS admitted between January 2013 and June 2023. In all patients, blood D-dimer levels increased significantly when they convalesced from OHSS and lost weight. None of the patients showed clinical signs of thrombosis, which was confirmed using imaging tests in 8 of 10 patients. Two patients underwent cell-free and concentrated ascites reinfusion therapy (CART), and their blood D-dimer levels increased dramatically after the procedure.

Conclusion

Weight change and CART are associated with blood D-dimer dynamics in OHSS. Our results show that elevated blood D-dimer levels in patients with OHSS do not always represent the presence of thrombosis. Reinfusion of pooled D-dimer in ascites may explain the D-dimer surge during the recovery phase or after CART in these patients. Our study provides new perspectives on the clinical implications of D-dimer during OHSS.

Optimal D-Dimer Cutoff Values for Diagnosing Deep Vein Thrombosis in Patients with Comorbid Malignancies

BACKGROUND

Patients with malignancy are at high risk of venous thromboembolism, and early diagnosis is important. The Khorana score is known as a risk assessment for cancer-related thrombosis during chemotherapy, but there are still few reports on its diagnostic potential, the optimal D-dimer cutoff values for indications other than chemotherapy and the use of the Khorana score in combination with D-dimers. In this study, we examined the clinical appropriateness of increasing the D-dimer cutoff value.

METHODS

We retrospectively studied 208 malignancies out of 556 patients who underwent lower extremity venous ultrasonography at our hospital over a 2-year period from January 2018 to December 2019. The optimal D-dimer cutoff value for predicting deep vein thrombosis (DVT) in patients with malignancy was calculated by the Youden index. The usefulness of the Khorana score alone and the model combining the Khorana score with D-dimer for predicting DVT diagnosis was compared using receiver operating characteristic analysis.

RESULTS

Of 208 eligible patients, 59 (28.4%) had confirmed DVT. The optimal D-dimer cutoff value for predicting DVT comorbidity in patients with malignancy was 3.96 μg/mL. When the new D-dimer cutoff value was set at 4.0 μg/mL, the odds ratio (OR) for DVT diagnosis was 4.23 (95% confidence interval (CI) 2.10-8.55, P < 0.001), which was higher than the OR of 1.33 (95% CI: 0.98-1.81, P = 0.064) for the Khorana score. The area under the curve for the Khorana score and D-dimer was 0.714, which was significantly higher than the 0.611 for the Khorana score alone, with the difference being significantly higher at 0.103 (P = 0.004, 95% CI: 0.033-0.173).

CONCLUSIONS

The optimal D-dimer cutoff value for the diagnosis of DVT in patients with malignancy was 4.0 μg/mL. It was also suggested that the combination of the Khorana score with the D-dimer level was more accurate in diagnosing DVT than the Khorana score alone.

A Predictive Model for Cancer-Associated Thrombosis in Japanese Cancer Patients: Findings from the J-Khorana Registry

Background  Although the close relationship between cancer and venous thromboembolism (VTE) has been identified, risk stratification for VTE in Japanese patients with cancer remains unclear. Objectives  This study aimed to validate the Khorana VTE risk assessment score (KRS) for VTE diagnosis and establish an optimal predictive model for VTE in Japanese patients with cancer. Methods  A total of 7,955 Japanese patients with cancer were subdivided into low- (0), intermediate- (1-2), and high-score (3) groups according to the KRS. Using 37 explanatory variables, a total of 2,833 patients with cancer were divided into derivation and validation cohorts (5:5). A risk model for Japanese participants was developed using the derivation cohort data. Results  The prevalence of VTE in low-, intermediate-, and high-score patients was 1.2, 2.5, and 4.3%, respectively. Logistic regression analysis demonstrated that cancer stage (III-IV) and KRS ≥ 2 were independent and significant predictors of VTE onset. The risk model for VTE assigned 1 point to body mass index ≥25 kg/m 2 and 2 points each to the prevalence of osteochondral cancer and D-dimer level ≥1.47 µg/mL. The areas under the curve of the risk model were 0.763 and 0.656 in the derivation and validation cohorts, respectively. Conclusion  The KRS was useful in Japanese patients, and our new predictive model may be helpful for the diagnosis of VTE in Japanese patients with cancer.

Asymptomatic Venous Thromboembolism After Hepatobiliary-Pancreatic Surgery: Early Detection Using D-dimer and Soluble Fibrin Monomer Complex Levels

AIM

The aim was to investigate the usefulness of a preemptive management strategy that includes monitoring serum D-dimer (DD) and soluble fibrin monomer complex (SFMC) levels for early detection and treatment of venous thromboembolism (VTE) after hepatobiliary-pancreatic (HBP) surgery.

METHODS

Overall, 678 patients who underwent HBP surgery between January 2010 and March 2020 were enrolled. Patients with increased postoperative serum DD or SFMC levels underwent contrast-enhanced computed tomography, and those with VTE received anticoagulant agents. The VTE risk factors were investigated using multivariable analysis. Postoperative changes in DD and SFMC levels were verified, and their ability to identify VTE was evaluated using receiver operating characteristic (ROC) analysis.

RESULTS

VTE developed in 83 patients (12.2%), and no symptomatic VTE or death due to VTE was observed. Multivariable analysis identified female sex (odds ratio [OR] 2.26; 95% confidence interval [CI] 1.41-3.60; P < .001) and surgery duration of ≥401 min (OR 2.07; 95% CI 1.27-3.35; P < .001) as independent risk factors for VTE. Maximum serum DD and SFMC levels in patients who developed VTE were significantly higher than those in patients without VTE (DD, 15.1 vs 8.9 μg/mL, P < .001; SFMC, 18.0 vs 10.2 μg/mL, P < .001, respectively). Both DD (n = 678) and the combination of DD and SFMC levels (n = 230) showed a good ability to detect VTE (area under the ROC curve, 0.804 and 0.761, respectively).

CONCLUSION

Our preemptive strategy of monitoring serum DD and SFMC levels enables early detection and treatment intervention of VTE after HBP surgery.

Validation of the Khorana Venous Thromboembolism Risk Score in Japanese Cancer Patients

Background

Although the Khorana venous thromboembolism (VTE) risk score (KRS) is well recognized as a simple VTE risk assessment method in patients with cancer, whether it is suitable for Asian populations is unclear.

Objectives

This study validated KRS for the prediction of VTE and investigated the value of the KRS in predicting mortality in Japanese patients with cancer.

Methods

A body mass index value of 25 kg/m² or more was defined as obesity according to World Health Organization consensus. A total of 27,687 patients with cancer were subdivided into low- (0), intermediate- (1-2), and high-score (3) groups by the KRS. The primary and secondary endpoints were VTE and all-cause mortality, respectively.

Results

The prevalence of VTE was 1.7%, 7.3%, and 11.0% for low-, intermediate-, and high-score patients, respectively. Receiver operating characteristic (ROC) analysis showed that the KRS significantly predicted VTE (area under the curve, 0.679; 95% confidence interval [CI] 0.666-0.692; P < 0.001). The cutoff value for the KRS was 1.0. Logistic regression analysis demonstrated that the KRS was an independent predictor of VTE (odds ratio 1.766; 95% CI 1.673-1.865; P < 0.01). The cutoff value of the KRS for all-cause mortality determined by ROC analysis was 2.0. Kaplan–Meier analysis demonstrated a significantly higher incidence of mortality in the KRS ≥2 group than in the KRS 0-1 group (log-rank: P < 0.01).

Conclusions

The KRS was useful in Japanese patients with cancer and might be a potentially useful marker for the prediction of mortality. Establishing optimal scores for Japanese subjects is mandatory because of its low diagnostic ability. (KUMAMON Cancer registry; UMIN000047554)

Coagulopathy and Venous Thromboembolic Events Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Background

Coagulopathy after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is recognized but few details have been studied.

Objectives

The aim of this study was to investigate changes in coagulation biomarkers and their predictive ability for venous thromboembolism (VTE).

Methods

Patients undergoing CRS and HIPEC at Uppsala University Hospital, Sweden, from 2004 to 2014 were included in a prospective study of coagulation biomarkers. Prothrombin time international normalized ratio (PT-INR), activated partial thromboplastin time (APTT), fibrinogen, antithrombin, D-dimer, and platelets were sampled on postoperative days 1, 2, 5, and 10. Logistic regression analysis was used to evaluate predictive capacity for coagulation-related complications.

Results

Overall, 380 patients were included (214 females, mean age 56 years); 38 patients had a history of thromboembolism and 57 were active smokers. Mean perioperative blood loss was 1228 mL and 231 (61%) received perioperative blood transfusions. PT-INR and APTT were elevated directly after surgery but returned to normal levels on postoperative day 5. Conversely, fibrinogen, platelet count, D-dimer, and antithrombin increased by postoperative day 5 and continued to increase up to day 10. There were 23 radiologically verified cases of VTE within 6 months. The multivariate analysis identified a completeness of cytoreduction score of 2–3 (p = 0.047) and day 2 D-dimer (p = 0.0082) as independent risk factors for postoperative VTE.

Conclusion

Significant postoperative changes in coagulation biomarkers occur with dynamic changes over 10 days postoperatively. The incidence of symptomatic VTE was low. Residual tumor at completion of surgery and elevated D-dimer on day 2 were independent risk factors for postoperative VTE.

Mechanisms and biomarkers of cancer-associated thrombosis

Cancer-associated thrombosis is a leading cause of non-cancer death in cancer patients and is comprised of both arterial and venous thromboembolism (VTE). There are multiple risk factors for developing VTE, including cancer type, stage, treatment, and other medical comorbidities, which suggests that the etiology of thrombosis is multifactorial. While cancer-associated thrombosis can be treated with anticoagulation, benefits of therapy must be balanced with the increased bleeding risks seen in patients with cancer. Although risk models exist for primary and recurrent VTE, additional predictors are needed to improve model performance and discrimination of high-risk patients. This review will outline the diverse mechanisms driving thrombosis in cancer patients, as well as provide an overview of biomarkers studied in thrombosis risk and important considerations when selecting candidate biomarkers.

Deep vein thrombosis and serum D-dimer after pelvic lymphadenectomy in gynecological cancer

INTRODUCTION

Venous thromboembolism prevention during the perioperative period requires comprehensive risk-level assessment. The aim of this study was to evaluate the incidence of deep vein thrombosis and to assess the cut-off levels of serum D-dimer as a screening strategy for deep vein thrombosis during the perioperative period.

METHODS

A total of 205 patients (ovarian cancer: 68, endometrial cancer: 76, cervical cancer: 61) who underwent gynecological surgery, including retroperitoneal lymph node dissection, were enrolled. We retrospectively analyzed the data on the cut-off value of D-dimer assessed using area under the receiver operating characteristic curve preoperatively, and 2 or 3 months, postoperatively. All patients underwent leg vein ultrasonography regardless of the serum D-dimer level. Furthermore, CT scans were performed to evaluate both disease status and venous thromboembolism, including pulmonary thromboembolism. Statistical analyzes were performed using the Mann-Whitney U-test (D-dimer values of each cancer), Chi-square test, Fisher's exact test (incidence of deep vein thrombosis), and one-way analysis of variance (patient characteristics).

RESULTS

A total of 205 patients (ovarian cancer: 68, endometrial cancer: 76, cervical cancer: 61) who underwent gynecological surgery, including retroperitoneal lymph node dissection, were included in the analysis. Deep vein thrombosis rates were significantly higher in patients with ovarian cancer (P<0.001). The postoperative D-dimer value was significantly higher than the preoperative value. Postoperative D-dimer values were also significantly higher in patients who received adjuvant chemotherapy (P=0.001). The cut-off value of D-dimer was 1.55 µg/mL preoperatively (sensitivity, 48.0%; specificity, 94.1%), and this value was higher postoperatively, at 1.95 µg/mL (sensitivity, 37.0%; specificity, 90.9%).

CONCLUSION

Postoperative D-dimer values are higher not only after surgery but also in patients who received adjuvant chemotherapy. The cut-off value of D-dimer at 2 or 3 months postoperatively was higher than preoperative value.

Biologic roles of the ABH and Lewis histo-blood group antigens part II: thrombosis, cardiovascular disease and metabolism

The ABH and Lewis antigens were among the first of the human red blood cell polymorphisms to be identified and, in the case of the former, play a dominant role in transfusion and transplantation. But these two therapies are largely twentieth-century innovations, and the ABH and related carbohydrate antigens are not only expressed on a very wide range of human tissues, but were present in primates long before modern humans evolved. Although we have learned a great deal about the biochemistry and genetics of these structures, the biological roles that they play in human health and disease are incompletely understood. This review and its companion, which appeared in a previous issue of Vox Sanguinis, will focus on a few of the biologic and pathologic processes which appear to be affected by histo-blood group phenotype. The first of the two reviews explored the interactions of two bacteria with the ABH and Lewis glycoconjugates of their human host cells, and described the possible connections between the immune response of the human host to infection and the development of the AB-isoagglutinins. This second review will describe the relationship between ABO phenotype and thromboembolic disease, cardiovascular disease states, and general metabolism.

Can Biomarkers of Coagulation, Platelet Activation, and Inflammation Predict Venous Thromboembolism in Patients with Haematological Malignancies?

BACKGROUND

The incidence of venous thromboembolism (VTE) in haematological malignancies varies according to the type and grade of the disease and clinical variables, and there is a need to develop a tool to predict the occurrence of VTE in cancer patients at diagnosis to tailor prophylactic anticoagulation use during treatment.

OBJECTIVE

To study the incidence of VTE in haematological malignancies and clarify whether vascular and inflammatory biomarkers could be used as predictors of VTE in those patients.

METHODS

This was a prospective observational cohort study. Hypercoagulability and inflammatory biomarkers were assayed in a group of 171 patients with haematological malignancies at diagnosis. These markers included (1) coagulation and fibrinolysis activation markers (D-dimer, fibrinogen, antithrombin, plasminogen activator inhibitor 1), (2) endothelial and platelet activation markers (von Willebrand factor and soluble P-selectin), and (3) inflammatory markers (tumour necrosis factor αand interleukin 6). The end point was mortality or symptomatic VTE.

RESULTS/CONCLUSION

The incidence of symptomatic VTE was 7%. None of the tested biomarkers showed statistical significance as predictors for the occurrence of VTE in haematological malignancies. However, there were statistically significant associations between the occurrence of VTE and central venous access device insertion, the prothrombin time, and the erythrocyte sedimentation rate. An ESR above 106.5 mm/h is associated with increased VTE occurrence.

Predicting VTE in Cancer Patients: Candidate Biomarkers and Risk Assessment Models

Risk prediction of chemotherapy-associated venous thromboembolism (VTE) is a compelling challenge in contemporary oncology, as VTE may result in treatment delays, impaired quality of life, and increased mortality. Current guidelines do not recommend thromboprophylaxis for primary prevention, but assessment of the patient's individual risk of VTE prior to chemotherapy is generally advocated. In recent years, efforts have been devoted to building accurate predictive tools for VTE risk assessment in cancer patients. This review focuses on candidate biomarkers and prediction models currently under investigation, considering their advantages and disadvantages, and discussing their diagnostic performance and potential pitfalls.

Incidence, risk factors, and outcomes of venous thromboembolism after oncologic surgery: A systematic review and meta-analysis

BACKGROUND

The risk and prognosis of VTE associated with oncologic surgery need to be quantified to guide patient management. We aimed to examine the availability of data and to report the incidence of venous thromboembolism (VTE) in cancer patients after surgery, as well as the clinical outcomes of VTE following oncologic surgery.

METHODS

We searched multiple databases for terms related to VTE after oncologic surgery from inception to November 1, 2017. A random-effects meta-analysis was done to calculate the pooled incidence of VTE.

RESULTS

Of the 8611 citations identified, 136 studies including 1,481,659 patients met the eligibility criteria. The overall incidence of VTE was estimated to be 2.3% (95% CI 2.1-2.5). Bone and soft tissue cancer (10.6%, 95% CI 2.9-18.2) and lung cancer (8.1%, 95% CI 3.7-12.6) were associated with the highest and second highest risk of postoperative VTE, respectively. Age (standardized mean difference [SMD] = 0.46, 95% CI 0.40-0.53; I² = 93.8%), radiation (OR 1.29, 95% CI 1.03-1.62; I² = 34.6%), transfusion (OR 1.96, 95% CI 1.48-2.59; I² = 57.0%), and operative time (SMD = 1.12, 95% CI 1.07-1.16; I² = 100%) were possible risk factors for postoperative VTE. Patients with VTE versus those without had increased odds of all-cause fatal events (11.15, 95% CI 4.07-30.56; I² = 92.0%).

CONCLUSIONS

The risk of VTE after oncologic surgery remains high, and this risk varied according to the cancer type, study region, surgical location, and thromboprophylactic strategy. VTE is associated with increased mortality at the early stage of cancer surgery.

Pulmonary vein stump thrombosis after left pneumonectomy, diagnosed based on a high plasma D-dimer level: a case report

A 69-year-old man with locally advanced squamous cell lung cancer in the left hilum underwent left upper sleeve lobectomy following neoadjuvant chemoradiotherapy with an S-1/cisplatin regimen. On postoperative day (POD) 5, the chest X-ray findings deteriorated, and computed tomography (CT) images showed pulmonary congestion of the left residual lung. We then performed emergent left completion pneumonectomy. Although the Postoperative course after re-operation was uneventful, and the patient was scheduled to be discharged on POD 12 when the serum creatinine level and plasma D-dimer level increased to 1.34 mg/dL and 17.4 µg/mL respectively. CT images revealed a giant thrombus in the left superior pulmonary vein (LSPV) stump, and we immediately started anticoagulant therapy of apixaban at 10 mg/day. We confirmed that the thrombus was reduced in size on POD 30, and the patient was discharged without any further complications. The elevated plasma D-dimer level was a key finding in this case for diagnosing pulmonary vein stump thrombosis (PVT) after left lung surgery. The 23 reported cases of PVT were found incidentally through follow-up CT scan or after serious complications occurred. This is the first case reporting the utility of the plasma D-dimer test for diagnosing PVT after surgical resection of the left lung. Early detection of PVT by a plasma D-dimer test may therefore positively contribute to better outcomes in the postoperative course of surgical resection of the left lung.

ABO blood types associated with the risk of venous thromboembolism in Han Chinese people: A hospital-based study of 200,000 patients

ABO blood types are putatively associated with the risk of venous thromboembolism (VTE), but it is not proved in Chinese people. A large population of Han Chinese patients discharged from Peking Union Medical College Hospital between January 2010 and June 2016 were retrospectively analyzed in a case-control study. A total of 1412 VTE patients were identified from 200,660 discharged Han Chinese patients, including 600 patients with deep vein thrombosis (DVT), 441 patients with pulmonary embolism, and 371 patients with both DVT and pulmonary embolism. The prevalence of non-O blood type was weakly but statistically higher in VTE patients compared with 199,248 non-VTE patients, with an odds ratio (OR) of 1.362 (95% confidence interval [CI], 1.205–1.540). Subgroup analysis showed that the OR for non-O blood type was still increased. It was greater in pre-hospital VTE (OR = 1.464) than that in hospital-acquired VTE (OR = 1.224), and greater in unprovoked VTE (OR = 1.859) than that in provoked VTE (OR = 1.227). The OR for non-O blood type decreased with age in subgroup analysis. These results suggest a weak but statistically significant correlation between non-O blood type and risk of VTE in Han Chinese people.

Evaluation of D-Dimer in Screening Deep Vein Thrombosis in Hospitalized Japanese Patients with Acute Medical Diseases/Episodes

Objective: To investigate the usefulness of D-dimer as a screening method as well as to explore potent predictors of deep vein thrombosis (DVT) in hospitalized Japanese patients with acute medical diseases/episodes. Methods and Subjects: This study was a multi-center, prospective, observational study. The inclusion criteria were hospitalized patients at high risk of developing venous thromboembolism with; (1) congestive heart failure, acute exacerbation of chronic obstructive pulmonary disease, infectious diseases, or inflammatory diseases, (2) bed rest ≥4 days, and (3) ≥60 years old. D-dimer was measured on the same day as ultrasonography. Multivariate logistic regression analysis was performed to investigate predictors associated with the presence of DVT. Results: Sixty-nine patients were enrolled. The prevalence of DVT was 33.3% (23/69; 95% C.I., 19.4% to 47.3%). D-dimer was measured in 42 patients and the sensitivity and negative predictive value reached 100%, while the specificity (13.3%) and positive predictive value (31.6%) were low (cut-off value: 0.9 or 1.0 µg/mL). Statistically significant predictor was not assigned. Conclusion: As the sensitivity and negative predictive value of D-dimer reached 100%, D-dimer have a role in excluding patients who might otherwise undergo diagnostic imaging for DVT in hospitalized Japanese patients with acute medical diseases/episodes.

ABO Blood Group and Risk of Thromboembolic and Arterial Disease: A Study of 1.5 Million Blood Donors

BACKGROUND

ABO blood groups have been shown to be associated with increased risks of venous thromboembolic and arterial disease. However, the reported magnitude of this association is inconsistent and is based on evidence from small-scale studies.

METHODS AND RESULTS

We used the SCANDAT2 (Scandinavian Donations and Transfusions) database of blood donors linked with other nationwide health data registers to investigate the association between ABO blood groups and the incidence of first and recurrent venous thromboembolic and arterial events. Blood donors in Denmark and Sweden between 1987 and 2012 were followed up for diagnosis of thromboembolism and arterial events. Poisson regression models were used to estimate incidence rate ratios as measures of relative risk. A total of 9170 venous and 24 653 arterial events occurred in 1 112 072 individuals during 13.6 million person-years of follow-up. Compared with blood group O, non-O blood groups were associated with higher incidence of both venous and arterial thromboembolic events. The highest rate ratios were observed for pregnancy-related venous thromboembolism (incidence rate ratio, 2.22; 95% confidence interval, 1.77-2.79), deep vein thrombosis (incidence rate ratio, 1.92; 95% confidence interval, 1.80-2.05), and pulmonary embolism (incidence rate ratio, 1.80; 95% confidence interval, 1.71-1.88).

CONCLUSIONS

In this healthy population of blood donors, non-O blood groups explain >30% of venous thromboembolic events. Although ABO blood groups may potentially be used with available prediction systems for identifying at-risk individuals, its clinical utility requires further comparison with other risk markers.

D-Dimer elevation and adverse outcomes

d-Dimer is a biomarker of fibrin formation and degradation. While a d-dimer within normal limits is used to rule out the diagnosis of deep venous thrombosis and pulmonary embolism among patients with a low clinical probability of venous thromboembolism (VTE), the prognostic association of an elevated d-dimer with adverse outcomes has received far less emphasis. An elevated d-dimer is independently associated with an increased risk for incident VTE, recurrent VTE, and mortality. An elevated d-dimer is an independent correlate of increased mortality and subsequent VTE across a broad variety of disease states. Therefore, medically ill subjects in whom the d-dimer is elevated constitute a high risk subgroup in which the prospective evaluation of the efficacy and safety of antithrombotic therapy is warranted.

Venous thrombosis and cancer: from mouse models to clinical trials

Cancer patients have a ~4 fold increased risk of venous thromboembolism (VTE) compared with the general population and this is associated with significant morbidity and mortality. This review summarizes our current knowledge of VTE and cancer, from mouse models to clinical studies. Notably, the risk of VTE varies depending on the type and stage of cancer. For instance, pancreatic and brain cancer patients have a higher risk of VTE than breast and prostate cancer patients. Moreover, patients with metastatic disease have a higher risk than those with localized tumors. Tumor-derived procoagulant factors and growth factors may directly and indirectly enhance VTE. For example, increased levels of circulating tumor-derived, tissue factor-positive microvesicles may trigger VTE. In a mouse model of ovarian cancer, tumor-derived IL-6 and hepatic thrombopoietin have been linked to increased platelet production and thrombosis. In addition, mouse models of mammary and lung cancer showed that tumor-derived granulocyte colony-stimulating factor causes neutrophilia and activation of neutrophils. Activated neutrophils can release neutrophil extracellular traps (NETs) that enhance thrombosis. Cell-free DNA in the blood derived from cancer cells, NETs and treatment with cytotoxic drugs can activate the clotting cascade. These studies suggest that there are multiple mechanisms for VTE in patients with different types of cancer. Preventing and treating VTE in cancer patients is challenging; the current recommendations are to use low-molecular-weight heparin. Understanding the underlying mechanisms may allow the development of new therapies to safely prevent VTE in cancer patients.

Early Identification of Asymptomatic Pulmonary Embolism Proximal to the Subsegmental Arteries After Gynecologic Surgery

Few studies have assessed whether cases of asymptomatic pulmonary embolism (PE) in the early postoperative phase are subsegmental versus more proximal. In this study, we investigated whether asymptomatic PE occurring just after gynecologic surgery was subsegmental, and we examined the background characteristics of patients who experienced PE within 2 months postoperatively. All hospital records were reviewed, yielding a total of 2052 women who had undergone surgeries performed by the gynecologic oncology team between 2003 and 2013 in the National Kyushu Cancer Center. Asymptomatic and symptomatic postoperative PE cases diagnosed by multidetector computed tomography angiography or lung scan were identified; after excluding 2 cases of preoperative PE, there were 15 (0.73%) cases of postoperative PE among 2050 women. Of the 15 cases, 9 (60%) were diagnosed on postoperative day 1 or 2. Of the 9 women, 4 had no or minor symptoms/signs other than decreased oxygen saturation as measured by pulse oximetry (Spo 2), and PE was segmental or more proximal in 3 cases. Only 1 of the 9 cases showed dyspnea. The remaining 4 cases showed dizziness or perspiration, suggesting PE. Univariate analysis showed age, operation time, hypertension, and preoperative d-dimer elevation to be associated with postoperative PE. Multivariate analysis demonstrated that a high (≥ 1 µg/mL) preoperative d-dimer level was associated with postoperative PE (odds ratio, 6.331; 95% confidence interval, 1.567-25.589). Most asymptomatic PE cases occurring within 2 days postoperatively were segmental or more proximal. Identification of early, asymptomatic postoperative PE may be clinically significant because most of these emboli are proximal to the subsegmental arteries.

Dimerized plasmin fragment D as a potential biomarker to predict successful catheter-directed thrombolysis therapy in acute deep vein thrombosis

Objectives

The value of dimerized plasmin fragment D in the clinical monitoring during the catheter-directed thrombolysis in patients with acute deep vein thrombosis is not known.

Methods

Dimerized plasmin fragment D levels in 24 patients with acute deep vein thrombosis undergoing catheter-directed thrombolysis were prospectively evaluated. The plasma dimerized plasmin fragment D level was measured serially before and at every 12 h during catheter-directed thrombolysis for 24 h. Technical success was defined as restoration of patency and flow with less than 50% residual thrombus by surveillance rotational venography.

Results

Technical success was achieved in 79.2% (19 of 24) of the treated limbs after catheter-directed thrombolysis. In univariate analysis, there was significant elevation of the dimerized plasmin fragment D at 12th h after starting the catheter-directed thrombolysis ( P < 0.05) in patients with less than 50% residual thrombus stenosis. The optimal cut-off value of dimerized plasmin fragment D to predict successful catheter-directed thrombolysis was determined as 18.4 µg/ml at the 12th h after starting the catheter-directed thrombolysis with sensitivity 0.8 and specificity 0.8 ( P = 0.03). It was further validated in multivariate logistic regression analysis (odds ratio: 14.38; 95% CI: 1.22–169.20; P = 0.03).

Conclusions

Catheter-directed thrombolysis is safe and effective for restoration of blood flow in patients with acute deep vein thrombosis. Dimerized plasmin fragment D value greater than 18.4 µg/ml at the 12th h after starting catheter-directed thrombolysis had a high predictive rate of greater than 50% lysis at the end of catheter-directed thrombolysis.

Biomarkers for prediction of venous thromboembolism in cancer. Blood. 2013;122:2011-2018. [PMID: 23908470 DOI: 10.1182/blood-2013-04-460147]

Cancer patients are at increased risk of deep vein thrombosis and pulmonary embolism. The incidence among different groups of cancer patients varies considerably depending on clinical factors, the most important being tumor entity and stage. Biomarkers have been specifically investigated for their capacity of predicting venous thromboembolism (VTE) during the course of disease. Parameters of blood count analysis (elevated leukocyte and platelet count and decreased hemoglobin) have turned out to be useful in risk prediction. Associations between elevated levels and future VTE have been found for d-dimer, prothrombin fragment 1+2, and soluble P-selectin and also for clotting factor VIII and the thrombin generation potential. The results for tissue factor-bearing microparticles are heterogeneous: an association with occurrence of VTE in pancreatic cancer might be present, whereas in other cancer entities, such as glioblastoma, colorectal, or gastric carcinoma, this could not be confirmed. Risk assessment models were developed that include clinical and laboratory markers. In the high-risk categories, patient groups with up to a >20% VTE rate within 6 months can be identified. A further improvement in risk stratification would allow better identification of patients for primary VTE prevention using indirect or novel direct anticoagulants.

The effect of cadmium on the coagulation and fibrinolytic system in women with uterine endometrial cancer and myoma

OBJECTIVES

Cadmium (Cd) is a persistent and widespread environmental pollutant, which may constitute a potential risk factor for hormone-dependent tumors such as endometrial cancer. The vascular endothelium is an important target of cadmium toxicity, which may interfere with the coagulation cascade and fibrinolytic system. The aim of this research was to investigate whether in female patients with uterine endometrial cancer or myoma in comparison to healthy women, the concentration of cadmium in blood affects the process of coagulation and fibrinolysis.

MATERIALS AND METHODS

The study group comprised 91 women: 35 healthy (A-control), 39 with uterine myoma (B) and 17 with endometrial cancer (C), in which blood cadmium concentrations (BCd), coagulation and selected fibrinolysis parameters in plasma were assayed.

RESULTS

In the women with myoma and especially in those with endometrial cancer disturbances in coagulation and fibrinolysis were detected when compared to the healthy women. In the group of women with endometrial cancer significant changes in prothrombin index, levels of fibrinogen, fibrin D-dimer and t-PA were observed. Whereas, in the patients with myoma significant changes in prothrombin time, index of vWillebrand Factor and fibrin D-dimer level were noted. Mean BCd concentrations in subsequent groups were as follows: B - 0.91±0.81; C - 0.78±0.45 μg Cd/l and did not differ significantly in comparison with the control group (0.86±0.35 μg Cd/l). However, in each study group smokers had approximately twice as high BCd as non-smokers. Studies also showed significant associations between BCd and fibrinogen level and thrombin time among the women with myoma and endometrial cancer, as well as in healthy women. Moreover, thrombin time significantly correlated with fibrinogen level in the women studied.

CONCLUSIONS

In the patients with myoma and especially in these with endometrial cancer disturbances in coagulation and fibrinolysis parameters leading to hypercoagulability were detected. Exposure to cadmium can be one of the factors inducing these changes.

Postoperative decreased levels of D-dimer in patients with gynecologic cancer with enoxaparin and fondaparinux thromboprophylaxis

The purpose of the present study was to evaluate the effects of enoxaparin (ENO) and fondaparinux (FPX) on postoperative plasma D-dimer levels and risk factors associated with postoperative venous thromboembolism (VTE) and pulmonary thromboembolism (PTE) in patients with gynecologic cancer. For this study, 434 patients with gynecologic cancer were recruited and a surgical treatment strategy was employed. Plasma D-dimer levels were measured prior to surgery, as well as on a schedule up to 3 weeks postoperatively and again after day 28. Patients with clinical signs and elevation of the plasma D-dimer level underwent multidetector row computed tomography. The D-dimer value was significantly lower in patients with ENO or FPX on postoperative days 3–10 compared to patients with gynecologic cancers who were not receiving ENO or FPX. The D-dimer value was significantly lower in patients with FPX compared to patients with ENO on postoperative days 5–7. The D-dimer value on postoperative day 3, the use of erythropoiesis-stimulating agents (ESAs), advancing age and non-O blood group were independent risk factors for postoperative VTE. The D-dimer value on postoperative day 3 and the use of ESAs were independent risk factors for postoperative PTE. The postoperative D-dimer value was significantly lower in patients with gynecologic cancer who were administered ENO or FPX compared to patients were not administered either ENO or FPX. The use of ESAs and high plasma D-dimer levels on postoperative day 3 were independent risk factors for postoperative VTE and PTE.

Elevated preoperative plasma D-dimer levels and the incidence of venous thromboembolism in Japanese females with gynecological cancer

The purpose of the present study was to determine the incidence of increased levels of D-dimer and associated factors in preoperative patients with gynecological cancer. Furthermore, we determined the incidence and risk factors associated with preoperative venous thromboembolism (VTE). Overall, 456 patients with invasive gynecological cancer scheduled to undergo surgery were recruited. Preoperative plasma D-dimer levels were measured and patients whose plasma D-dimer concentration exceeded the pre-set cut-off value underwent computed tomography scanning. The incidence of elevated D-dimer and VTE was identified as significantly higher in patients with ovarian cancer. Multivariate analysis revealed that advanced age, low hemoglobin levels and elevated C-reactive protein (CRP) levels were independent factors for preoperative elevations in plasma D-dimer levels. Advanced age was an independent risk factor for preoperative VTE. Massive ascites and the presence of co-morbidities were independent risk factors for preoperative VTE in ovarian cancer. Advanced age and stage were independent risk factors for preoperative VTE in endometrial cancer. Advanced age was an independent risk factor for preoperative VTE in cervical cancer. Plasma D-dimer levels and the incidence of preoperative VTE were higher in patients with ovarian cancer compared with those with other gynecological cancers. Advanced age, low hemoglobin levels and elevated CRP levels were significant factors associated with elevated plasma D-dimer levels and age was an independent risk factor for preoperative VTE in gynecological cancer.

Evaluation of Risk Factors for Venous Thromboembolism in Chinese Women With Epithelial Ovarian Cancer

Objective

Venous thromboembolism (VTE) is a life-threatening complication that often occurs in ovarian tumors. However, the risk factors for VTE are still undetermined.

Methods

We retrospectively analyzed VTE occurrence and its potential risk factors in 254 Chinese patients with ovarian tumor at Fudan University Cancer Hospital from July 2007 to June 2011.

Results

The VTE incidence was 7.1% (13/183) in epithelial ovarian cancer (EOC), and no VTE was found in ovarian borderline or benign tumor. D-dimer levels were significantly higher in EOC than in ovarian benign and borderline tumors. Furthermore, D-dimer levels increased with the advancement of EOC stages. Correlation analysis suggested that D-dimer levels were well correlated with platelet counting (PLT), prothrombin time (PT), white blood cell counting (WBC), cancer antigen (CA) 125, and CA153. Univariate logistic regression analysis found that D-dimer levels greater than 788 μg/L, PLT levels greater than 261 × 109/L, PT greater than 11.7 seconds, CA125 greater than 760 U/mL, and ascites greater than 1500 mL are risk factors for VTE in EOC. Moreover, multivariate analysis grouped primary EOC, low differentiated grade, D-dimer greater than 788 μg/L, PT greater than 11.7 seconds, and CA125 greater than 760 U/mL as prediction factors for VTE.

Conclusions

In addition to D-dimer and ascites, high levels of PLT, PT, and CA125, which are highly correlated with D-dimer, are independent risk factors for VTE

Changes in soluble fibrin levels during the perioperative period of gynecologic cancer surgery

The purpose of this study was to evaluate the changes in plasma soluble fibrin (SF) levels over time in gynecologic cancer patients following surgery. Furthermore, we examined the duration of the coagulation stage and determined a suitable duration for which thromboprophylaxis with anticoagulant agents should be administered. We retrospectively studied 311 patients with invasive gynecologic cancer who underwent surgery at Okayama University Hospital, Japan. The plasma SF levels were measured serially prior to the operation and on postoperative days 0, 1, 3, 5, 7, 10, 14, 21 and 28. The plasma SF levels increased rapidly, peaked on postoperative day 1 and then decreased. The SF levels of patients with venous thromboembolism (VTE) were significantly different from those of VTE-negative patients on postoperative days 0-10. The SF levels on each day did not significantly differ between patients treated with chemical anticoagulants and those treated mechanically. The plasma SF levels were elevated (≥7.0 μg/ml) in 159 of the 311 patients (51.1%) on one of the days when these levels were measured. Among the patients with elevated plasma SF levels, 110 patients (69.2%) peaked on days 0-3 and only 9 patients (5.7%) peaked on days 21-28. Although only 1 of the 14 patients (7.1%) who showed peak levels on day 14 had undergone chemotherapy following surgery, 8 of the 9 patients (88.9%) whose levels peaked on days 21-28 had undergone chemotherapy following surgery (P= 0.0002). In conclusion, the plasma SF levels increased rapidly, peaked on postoperative day 1 and then decreased. These levels peaked within 14 days of surgery in most cases. Therefore, chemical thromboprophylaxis may be administered for at least up to 14 days following surgery.

The role of thromboprophylaxis in cancer patients: emerging data

PURPOSE OF REVIEW

Venous thromboembolism (VTE) is a frequent cause of morbidity and mortality in cancer patients. A significant proportion of cancer-associated VTE occurs in the ambulatory setting and is associated with poorer outcomes and reduced survival. Risk for VTE is influenced by patient, cancer and treatment-specific factors.

RECENT FINDINGS

Recent studies have identified biomarkers associated with increased VTE risk in malignancy, including leukocyte and platelet counts, tissue factor, prothrombin split products, D-dimer, P-selectin, factor VIII and C-reactive protein. Recent and ongoing clinical trials have focused on VTE prophylaxis with low-molecular weight heparins in high-risk cancer outpatients, particularly those with pancreatic cancer. These studies have yielded encouraging preliminary results but whether thromboprophylaxis provides significant benefit to unselected cancer outpatients remains unclear.

SUMMARY

A risk stratification model incorporating known risk factors and biomarkers can identify those patients at highest risk. This review focuses on emerging data regarding risk assessment and benefit of thromboprophylaxis in patients with cancer.

Risk factors for perioperative venous thromboembolism: A retrospective study in Japanese women with gynecologic diseases

BACKGROUND

Patients with gynecologic cancer have a high risk of venous thromboembolism (VTE) like patients with other cancers. However, there is little information on risk factors for VTE during gynecologic surgery and no uniform preventive strategy. Our objectives were to identify risk factors for perioperative VTE in gynecologic patients and establish methods for prevention.

METHODS

We analyzed 1,232 patients who underwent surgery at the Department of Obstetrics and Gynecology of St. Marianna University School of Medicine between January 2005 and June 2008. We investigated (1) risk factors for preoperative VTE, (2) use of an inferior vena cava (IVC) filter, and (3) risk factors for postoperative VTE.

RESULTS

There were 39 confirmed cases of perioperative VTE (3.17%), including 25 patients with preoperative VTE and 14 with postoperative VTE. Thirty-two patients had cancer and seven patients had benign diseases. Twenty-two of the 32 cancer patients (68.7%) had preoperative VTE, while postoperative VTE occurred in 10 cancer patients. Multivariate analysis indicated that ovarian cancer, tumor diameter ≥10 cm, and previous of VTE were independent risk factors for preoperative VTE. Among ovarian cancer patients, multivariate analysis showed that an age ≥50 years, the presence of heart disease, clear cell adenocarcinoma, and tumor diameter ≥20 cm were independent risk factors for preoperative VTE. The factors significantly related to preoperative VTE in patients with benign disease included previous VTE, age ≥55 years, tumor diameter ≥20 cm, and a history of allergic-immunologic disease. Thirteen of the 25 patients (52%) with preoperative VTE had an IVC filter inserted preoperatively. Postoperative screening (interview and D-dimer measurement) revealed VTE in 14/1,232 patients (1.14%). Multivariate analysis indicated that cancer surgery, a history of allergic-immunologic disease, and blood transfusion ≥2,000 ml were independent risk factors for postoperative VTE.

CONCLUSIONS

Perioperative VTE is often fatal and preventive measures should be taken in the gynecologic field, especially when patients have the risk factors identified in this study. Since VTE is often present before surgery, preoperative screening is important and use of an IVC filter should be considered.