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Englisch C, Moik F, Thaler J, Koder S, Mackman N, Preusser M, Pabinger I, Ay C. Tissue factor pathway inhibitor is associated with risk of venous thromboembolism and all-cause mortality in patients with cancer. Haematologica 2024; 109:1128-1136. [PMID: 37822244 PMCID: PMC10985431 DOI: 10.3324/haematol.2023.283581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/03/2023] [Indexed: 10/13/2023] Open
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer. Data on the role of natural inhibitors of coagulation for occurrence of cancer-associated VTE are limited, thus, we investigated the association of tissue factor pathway inhibitor (TFPI) with risk of VTE and all-cause mortality in patients with cancer. Total TFPI antigen levels were measured with a commercially available enzyme-linked immunosorbant assay in patients included in the Vienna Cancer and Thrombosis Study, a prospective observational cohort study with the primary outcome VTE. Competing risk analysis and Cox regression analysis were performed to explore the association of TFPI levels with VTE and all-cause mortality. TFPI was analyzed in 898 patients (median age 62 years; interquartile range [IQR], 53-68; 407 (45%) women). Sixty-seven patients developed VTE and 387 died (24-month cumulative risk 7.5% and 42.1%, respectively). Patients had median TFPI levels at study inclusion of 56.4 ng/mL (IQR, 45.7-70.0), with highest levels in tumor types known to have a high risk of VTE (gastroesophageal, pancreatic and brain cancer: 62.0 ng/mL; IQR, 52.0-75.0). In multivariable analysis adjusting for age, sex, cancer type and stage, TFPI levels were associated with VTE risk (subdistribution hazard ratio per doubling =1.63, 95% confidence interval [CI]: 1.03-2.57). When patients with high and intermediate/low VTE risk were analyzed separately, the association remained independently associated in the high risk group only (subdistribution hazard ratio =2.63, 95% CI: 1.40-4.94). TFPI levels were independently associated with all-cause mortality (hazard ratio =2.36, 95% CI: 1.85-3.00). In cancer patients increased TFPI levels are associated with VTE risk, specifically in patients with high-risk tumor types, and with all-cause mortality.
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Affiliation(s)
- Cornelia Englisch
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna; Vienna
| | - Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna; Vienna, Austria; Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz
| | - Johannes Thaler
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna; Vienna
| | - Silvia Koder
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna; Vienna
| | - Nigel Mackman
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna; Vienna
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna; Vienna
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna; Vienna.
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Moik F, Riedl JM, Ay C. Correspondence to: Amivantamab plus chemotherapy with and without lazertinib in EGFR-mutant advanced NSCLC after disease progression on osimertinib: primary results from the phase III MARIPOSA-2 study. Ann Oncol 2024; 35:327. [PMID: 38092622 DOI: 10.1016/j.annonc.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 02/25/2024] Open
Affiliation(s)
- F Moik
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna; Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - J M Riedl
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - C Ay
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna.
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Moik F, Riedl JM, Englisch C, Ay C. Update on Thrombosis Risk in Patients with Cancer: Focus on Novel Anticancer Immunotherapies. Hamostaseologie 2024; 44:40-48. [PMID: 38190985 DOI: 10.1055/a-2215-9909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Abstract
Thromboembolic complications, including venous thromboembolism (VTE) and arterial thromboembolism (ATE), increase mortality and morbidity, and delay treatment in patients with cancer. Therefore, an increased understanding of underlying risk profiles, the identification of risk factors and predictive biomarkers, and ultimately the development of specific cardiovascular prevention strategies in patients with cancer is needed. Medical anticancer therapies have undergone a remarkable development in recent years with the advent of targeted and immunotherapeutic treatment options, including immune checkpoint inhibitors (ICI), chimeric antigen receptor (CAR) T-cell therapies and bispecific T-cell engagers (BiTEs). These developments have important implications for the accompanied risk of thromboembolic events in patients with cancer. First, the increased use of these highly effective therapies renders a growing proportion of patients with cancer at risk of thromboembolic events for a prolonged risk period due to an increase in patient survival despite advanced cancer stages. Second, potential direct cardiovascular toxicity and prothrombotic effect of novel anticancer immunotherapies are a matter of ongoing debate, with emerging reports suggesting a relevant risk of VTE and ATE associated with ICI, and relevant dysregulations of hemostasis in the frequently observed cytokine-release syndrome associated with BiTEs and CAR T-cell therapy. The aim of the present narrative review is to summarize the implications of the emerging use of anticancer immunotherapy for thromboembolic events in patients with cancer, and to provide an overview of available data on the rates and risk factors for VTE and ATE associated with ICI, CAR T-cell therapy, and BiTEs.
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Affiliation(s)
- Florian Moik
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jakob M Riedl
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Cornelia Englisch
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Riedl JM, Moik F, Esterl T, Kostmann SM, Gerger A, Jost PJ. Molecular diagnostics tailoring personalized cancer therapy-an oncologist's view. Virchows Arch 2024; 484:169-179. [PMID: 37982847 PMCID: PMC10948510 DOI: 10.1007/s00428-023-03702-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 10/27/2023] [Accepted: 11/04/2023] [Indexed: 11/21/2023]
Abstract
Medical oncology is rapidly evolving with the implementation of personalized, targeted therapies. Advances in molecular diagnostics and the biologic understanding of cancer pathophysiology led to the identification of specific genetic alterations as drivers of cancer progression. Further, improvements in drug development enable the direct interference with these pathways, which allow tailoring personalized treatments based on a distinct molecular characterization of tumors. Thereby, we are currently experiencing a paradigm-shift in the treatment of cancers towards cancer-type agnostic, molecularly targeted, personalized therapies. However, this concept has several important hurdles and limitations to overcome to ultimately increase the proportion of patients benefitting from the precision oncology approach. These include the assessment of clinical relevancy of identified alterations, capturing and interpreting levels of heterogeneity based on intra-tumoral or time-dependent molecular evolution, and challenges in the practical implementation of precision oncology in routine clinical care. In the present review, we summarize the current state of cancer-agnostic precision oncology, discuss the concept of molecular tumor boards, and consider current limitations of personalized cancer therapy. Further, we provide an outlook towards potential future developments including the implementation of functionality assessments of identified genetic alterations and the broader use of liquid biopsies in order to obtain more comprehensive and longitudinal genetic information that might guide personalized cancer therapy in the future.
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Affiliation(s)
- Jakob M Riedl
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Moik
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Tamara Esterl
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Sarah M Kostmann
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Armin Gerger
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp J Jost
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
- Medical Department III for Haematology and Oncology, School of Medicine, Technical University of Munich, Munich, Germany.
- BioTechMed-Graz, Graz, Austria.
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Barth DA, Moik F, Steinlechner S, Posch F, Mayer MC, Sandner AM, Berton F, Schlintl V, Koch L, John N, Wurm R, Pichler M, Bauernhofer T, Reimann P, Wohlkönig C, Richtig E, Winder T, Preusser M, Jost PJ, Ay C, Gerger A, Terbuch A, Riedl JM. Early kinetics of C reactive protein for cancer-agnostic prediction of therapy response and mortality in patients treated with immune checkpoint inhibitors: a multicenter cohort study. J Immunother Cancer 2023; 11:e007765. [PMID: 38097343 PMCID: PMC10729183 DOI: 10.1136/jitc-2023-007765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND C reactive protein (CRP) kinetics have recently been suggested as predictive biomarkers for the efficacy of immune checkpoint inhibitor (ICI) therapy in selected cancer types. The aim of this study was to characterize early CRP kinetics as a tumor-agnostic biomarker for ICI treatment outcomes. METHODS In this multicenter retrospective cohort study, two independent cohorts of patients with various cancer types undergoing palliative ICI treatment at Austrian academic centers served as the discovery (n=562) and validation cohort (n=474). Four different patterns of CRP kinetics in the first 3 months of ICI therapy were defined (CRP-flare responders, CRP-responders, CRP non-responders, patients with all-normal CRP). Objective response rate (ORR), progression-free survival (PFS) and overall survival (OS) were defined as coprimary endpoints. Univariable and multivariable logistic regression, landmark analysis and Cox regression including CRP kinetics as time-dependent variable were performed. RESULTS The ORR in patients with all-normal CRP, CRP responders, CRP flare-responders and CRP non-responders was 41%, 38%, 31% and 12%, respectively. The median OS and PFS estimates were 24.5 months (95% CI 18.5 to not reached) and 8.2 months (95% CI 5.9 to 12.0) in patients with all-normal CRP, 16.1 months (95% CI 12.6 to 19-8) and 6.1 months (95% CI 4.9 to 7.2) in CRP-responders, 14.0 months (95% CI 8.5 to 19.4) and 5.7 months (95% CI 4.1 to 8.5) in CRP flare-responders and 8.1 months (95% CI 5.8 to 9.9) and 2.3 months (95% CI 2.2 to 2.8) in CRP non-responders (log-rank p for PFS and OS<0.001). These findings prevailed in multivariable analysis and could be fully confirmed in our validation cohort. Pooled subgroup analysis suggested a consistent predictive significance of early CRP kinetics for treatment efficacy and outcome independent of cancer type. CONCLUSION Early CRP kinetics represent a tumor-agnostic predictor for treatment response, progression risk and mortality in patients with cancer undergoing ICI therapy.
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Affiliation(s)
- Dominik A Barth
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Moik
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Sarah Steinlechner
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Posch
- Division of Hematology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Marie-Christina Mayer
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Amelie M Sandner
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Franziska Berton
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Verena Schlintl
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Lukas Koch
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Nikolaus John
- Division of Pulmonology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Robert Wurm
- Division of Pulmonology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Pichler
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Translational Oncology, University Hospital Augsburg, Augsburg, Germany
| | - Thomas Bauernhofer
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Patrick Reimann
- Internal Medicine II, Department of Hematology, Oncology, Gastroenterology and Infectiology, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Christoph Wohlkönig
- Division of Pulmonology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Erika Richtig
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Thomas Winder
- Internal Medicine II, Department of Hematology, Oncology, Gastroenterology and Infectiology, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Matthias Preusser
- Division of Oncology, Department of Medicine 1, Medizinische Universitat Wien, Wien, Austria
- Christian Doppler Laboratory for Personalized Immunotherapy, Medical University of Vienna, Vienna, Austria
| | - Philipp J Jost
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Armin Gerger
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Angelika Terbuch
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jakob Michael Riedl
- Division of Oncology; Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Kraemmer D, Königsbrügge O, Moik F, Wildner B, Ay C, Pabinger I. Pharmacokinetic-guided versus standard prophylaxis in hemophilia: a systematic review and meta-analysis. J Thromb Haemost 2023; 21:3432-3449. [PMID: 37739039 DOI: 10.1016/j.jtha.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/11/2023] [Accepted: 08/29/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND With population pharmacokinetic (PK) modeling more readily available and PK-guided prophylaxis endorsed by current hemophilia guidelines, we conducted a systematic review to summarize current evidence in the literature. OBJECTIVES To assess the efficacy of PK-guided compared with non-PK-guided prophylaxis. METHODS We did not restrict inclusion to specific study design labels and included all studies consisting of at least one distinct cohort arm receiving PK-guided prophylaxis. We searched the following databases from inception to date of search: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and the EU Clinical Trial Register. Following title, abstract, and full-text screening conducted independently by 2 review authors, we summarized studies qualitatively and synthesized included randomized clinical trials (RCTs) quantitatively by fitting random-effects models. RESULTS Search of databases on February 3, 2023, yielded 25 studies fitting our inclusion criteria. Of those, only 2 RCTs and 17 nonrandomized studies included a standard prophylaxis comparator group. Furthermore, risk of bias in the latter was substantial, primarily due to before-after study designs and retrospective comparator groups. Thus, nonrandomized studies were only presented qualitatively. A random-effects meta-analysis of the 2 identified RCT remained inconclusive with regards to bleeding outcomes (ratio of means, 1.15; 95% CI, 0.85-1.56) and factor consumption (ratio of means, 0.82; 95% CI, 0.58-1.18). CONCLUSION Evidence in the literature suggesting a clinical benefit of PK-guided over standard fixed-dose prophylaxis was weak and mainly found in nonrandomized studies limited by lack of concurrent controls, heterogeneity in outcome reporting, small sample sizes, and high risk of bias.
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Affiliation(s)
- Daniel Kraemmer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Oliver Königsbrügge
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Moik
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria; Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Brigitte Wildner
- University Library, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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Nopp S, Moik F, Kraler S, Englisch C, Preusser M, von Eckardstein A, Pabinger I, Lüscher TF, Ay C. Growth differentiation factor-15 and prediction of cancer-associated thrombosis and mortality: a prospective cohort study. J Thromb Haemost 2023; 21:2461-2472. [PMID: 37192696 DOI: 10.1016/j.jtha.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Patients with cancer are at increased risk of venous thromboembolism (VTE) and arterial thromboembolic/thrombotic events (ATEs). Growth differentiation factor-15 (GDF-15) improves cardiovascular risk assessment, but its predictive utility in patients with cancer remains undefined. OBJECTIVES To investigate the association of GDF-15 with the risks of VTE, ATE, and mortality in patients with cancer and its predictive utility alongside established models. METHODS The Vienna Cancer and Thrombosis Study (CATS)-a prospective, observational cohort study of patients with newly diagnosed or recurrent cancer-which was followed for 2 years, served as the study framework. Serum GDF-15 levels at study inclusion were measured, and any association with VTE, ATE, and death was determined using competing risk (VTE/ATE) or Cox regression (death) modeling. The added value of GDF-15 to established VTE risk prediction models was assessed using the Khorana and Vienna CATScore. RESULTS Among 1531 included patients with cancer (median age, 62 years; 53% men), median GDF-15 levels were 1004 ng/L (IQR, 654-1750). Increasing levels of GDF-15 were associated with the increased risks of VTE, ATE, and all-cause death ([subdistribution] hazard ratio per doubling, 1.16 [95% CI, 1.03-1.32], 1.30 [95% CI, 1.11-1.53], and 1.57 [95% CI, 1.46-1.69], respectively). After adjustment for clinically relevant covariates, the association only prevailed for all-cause death (hazard ratio, 1.21; 95% CI, 1.10-1.33) and GDF-15 did not improve the performance of the Khorana or Vienna CATScore. CONCLUSION GDF-15 is strongly associated with survival in patients with cancer, independent of the established risk factors. While an association with ATE and VTE was identified in univariable analysis, GDF-15 was not independently associated with these outcomes and failed to improve established VTE prediction models.
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Affiliation(s)
- Stephan Nopp
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Moik
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria; Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria. http://www.twitter.com/FlorianMoik
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland. http://www.twitter.com/KralerSimon
| | - Cornelia Englisch
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Clinical Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Arnold von Eckardstein
- Institute of Clinical Chemistry, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland; Royal Brompton and Harefield Hospitals and Imperial College, London, UK; School of Cardiovascular Medicine and Sciences, King's College London, London, UK. http://www.twitter.com/TomLuscher
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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Mauracher LM, Hell L, Moik F, Krall M, Englisch C, Roiß J, Grilz E, Hofbauer TM, Brostjan C, Knapp S, Ay C, Pabinger I. Neutrophils in lung cancer patients: activation potential and neutrophil extracellular trap formation. Res Pract Thromb Haemost 2023; 7:100126. [PMID: 37063752 PMCID: PMC10099311 DOI: 10.1016/j.rpth.2023.100126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/17/2023] Open
Abstract
Background Patients with cancer have an increased risk of developing venous thromboembolism. Neutrophils and neutrophil extracellular traps (NETs) reportedly influence the risk of cancer-associated thrombosis. Subpopulations of high and low-density neutrophils (HDN/LDN) are of specific interest, as they might have different functions in cancer patients. Objectives We aimed to investigate differences between HDNs and LDNs of patients with lung cancer and healthy controls, and their ability of activation and NET formation. Methods Within the framework of the Vienna Cancer and Thrombosis Study, a prospective observational cohort study, HDNs and LDNs from 20 patients with lung cancer and 20 controls were isolated by density gradient centrifugation. The ability of neutrophil subpopulations for activation and NET formation was investigated by flow cytometry. Results Compared to controls, patients with cancer had higher numbers of total leukocytes, HDNs, and LDNs. LDNs of patients were more frequently in an activated state (CD62L↓/CD16↑) at baseline (median [IQR] 5.9% [3.4-8.8] vs 2.5% [1.6-6.7]). HDNs and LDNs from patients showed a significantly increased response to stimulation with ionomycin (CD11b HDN: 98.5 [95.4-99.4] vs 41.7 [13.4-91.6]; LDN: 82.9 [63-94] vs 39.6 [17.3-72.1]). In addition, HDNs from patients showed a higher capability of NET formation after ionomycin stimulation compared to HDNs from healthy controls (18509.5 [12242.5-29470.3] vs 10001 [6618.8-18384.3]). Conclusion Protumorigenic LDNs were elevated, and neutrophil subpopulations showed an increased activation profile and ability for NET formation in patients with cancer. These mechanisms might be involved in tumor promotion and contribute to the prothrombotic phenotype of neutrophils in cancer.
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Ay C, Grilz E, Nopp S, Moik F, Königsbrügge O, Klimek P, Thurner S, Posch F, Pabinger I. Atrial fibrillation and cancer: prevalence and relative risk from a nationwide study. Res Pract Thromb Haemost 2023; 7:100026. [PMID: 36891526 PMCID: PMC9986100 DOI: 10.1016/j.rpth.2022.100026] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/17/2022] [Accepted: 11/23/2022] [Indexed: 01/15/2023] Open
Abstract
Background Atrial fibrillation (AF) is an increasingly recognized codiagnosis in patients with cancer. Objectives This study aimed to provide a robust and contemporary estimate on the coprevalence and relative risk of AF in patients with cancer. Methods We conducted a nationwide analysis, utilizing diagnosis codes from the Austrian Association of Social Security Providers dataset. Estimates of the coprevalence of cancer and AF and the relative risk of AF in patients with cancer compared with individuals without cancer were obtained as point prevalences with binomial exact confidence intervals and summarized across age groups and cancer types with random-effects models. Results Overall, 8,306,244 persons were included in the present analysis, of whom 158,675 (prevalence estimate, 1.91%; 95% CI, 1.90-1.92) had a cancer diagnosis code and 112,827 (1.36%; 95% CI, 1.35-1.36) an AF diagnosis code, respectively. The prevalence estimate for AF in patients with cancer was 9.77% (95% CI, 9.63-9.92) and 1.19% (95% CI, 1.19-1.20) in the noncancer population. Conversely, 13.74% (95% CI, 13.54-13.94) of patients with AF had a concurrent cancer diagnosis. The corresponding age-stratified random-effects relative risk ratio for AF in patients with cancer compared with no cancer diagnosis was 10.45 (95% CI, 7.47-14.62). The strongest associations between cancer and AF were observed in younger persons and patients with hematologic malignancies. Conclusion Cancer and AF have a substantial coprevalence in the population. This finding corroborates the concept that cancer and AF have common risk factors and pathophysiology.
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Affiliation(s)
- Cihan Ay
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ella Grilz
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Stephan Nopp
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Moik
- Department of Medicine I, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Peter Klimek
- Section for Science of Complex Systems, CEMSIIS, Medical University of Vienna, Vienna, Austria.,Complexity Science Hub Vienna, Vienna, Austria
| | - Stefan Thurner
- Section for Science of Complex Systems, CEMSIIS, Medical University of Vienna, Vienna, Austria.,Complexity Science Hub Vienna, Vienna, Austria.,Santa Fe Institute, Santa Fe, New Mexico, USA
| | - Florian Posch
- Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ingrid Pabinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Moik F, Ay C. Hemostasis and cancer: Impact of haemostatic biomarkers for the prediction of clinical outcomes in patients with cancer. J Thromb Haemost 2022; 20:2733-2745. [PMID: 36106749 PMCID: PMC9827869 DOI: 10.1111/jth.15880] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/09/2022] [Accepted: 09/13/2022] [Indexed: 01/13/2023]
Abstract
Patients with cancer are characterized by a dysregulation of the hemostatic system and systemic hypercoagulability. Different components of the hemostatic system are involved in tumor-promoting mechanisms including primary tumor growth, cancer cell invasion, immune evasion, angiogenesis, and the metastatic process. Therefore, different degrees of systemic hemostatic activation in patients with cancer can reflect distinct underlying biological phenotypes of cancer and seem to correlate with cancer aggressiveness. Peripheral blood levels of hemostatic biomarkers, indicating the activation status of different parts of the hemostatic system including the coagulation cascade, fibrinolytic activity, platelet activation, or endothelial activation, can be used to reflect cancer-associated systemic hypercoagulability. Thereby, hemostatic biomarkers represent promising candidates to investigate as surrogate markers for underlying cancer activity and progression dynamics and therefore as biomarkers for the prediction of clinical outcomes in cancer patients. In the present review, we provide an up-to-date summary of available data on hemostatic biomarkers for prognostication of overall survival and prediction of therapy response in patients with cancer, including specific oncologic treatment settings for potential clinical application. We provide a thorough discussion on potential clinical implementation and current limitations and highlight the most promising emerging biomarkers that might be used to contribute to risk-stratified, personalized oncologic decision making in the future.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of ViennaViennaAustria
- Clinical Division of Oncology, Department of Internal Medicine, Medical University of GrazGrazAustria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of ViennaViennaAustria
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11
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Haider P, Kral-Pointner JB, Salzmann M, Moik F, Bleichert S, Schrottmaier WC, Kaun C, Brekalo M, Fischer MB, Speidl WS, Hengstenberg C, Podesser BK, Huber K, Pabinger I, Knapp S, Brombacher F, Brostjan C, Ay C, Wojta J, Hohensinner PJ. Interleukin-4 receptor alpha signaling regulates monocyte homeostasis. FASEB J 2022; 36:e22532. [PMID: 36063138 PMCID: PMC9544925 DOI: 10.1096/fj.202101672rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 12/01/2022]
Abstract
Interleukin‐4 (IL‐4) and its receptors (IL‐4R) promote the proliferation and polarization of macrophages. However, it is unknown if IL‐4R also influences monocyte homeostasis and if steady state IL‐4 levels are sufficient to affect monocytes. Employing full IL‐4 receptor alpha knockout mice (IL‐4Rα−/−) and mice with a myeloid‐specific deletion of IL‐4Rα (IL‐4Rαf/f LysMcre), we show that IL‐4 acts as a homeostatic factor regulating circulating monocyte numbers. In the absence of IL‐4Rα, murine monocytes in blood were reduced by 50% without altering monocytopoiesis in the bone marrow. This reduction was accompanied by a decrease in monocyte‐derived inflammatory cytokines in the plasma. RNA sequencing analysis and immunohistochemical staining of splenic monocytes revealed changes in mRNA and protein levels of anti‐apoptotic factors including BIRC6 in IL‐4Rα−/− knockout animals. Furthermore, assessment of monocyte lifespan in vivo measuring BrdU+ cells revealed that the lifespan of circulating monocytes was reduced by 55% in IL‐4Rα−/− mice, whereas subcutaneously applied IL‐4 prolonged it by 75%. Treatment of human monocytes with IL‐4 reduced the amount of dying monocytes in vitro. Furthermore, IL‐4 stimulation reduced the phosphorylation of proteins involved in the apoptosis pathway, including the phosphorylation of the NFκBp65 protein. In a cohort of human patients, serum IL‐4 levels were significantly associated with monocyte counts. In a sterile peritonitis model, reduced monocyte counts resulted in an attenuated recruitment of monocytes upon inflammatory stimulation in IL‐4Rαf/f LysMcre mice without changes in overall migratory function. Thus, we identified a homeostatic role of IL‐4Rα in regulating the lifespan of monocytes in vivo.
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Affiliation(s)
- Patrick Haider
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Julia B Kral-Pointner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Manuel Salzmann
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Florian Moik
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sonja Bleichert
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Waltraud C Schrottmaier
- Institute of Vascular Biology and Thrombosis Research, Medical University of Vienna, Vienna, Austria
| | - Christoph Kaun
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Mira Brekalo
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Michael B Fischer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria.,Department of Biomedical Research, Danube University Krems, Krems, Austria
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Bruno K Podesser
- Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Ingrid Pabinger
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sylvia Knapp
- Laboratory of Infection Biology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Frank Brombacher
- Institute of Infectious Disease and Molecular Medicine, International Center for Genetic and Biotechnology Cape Town Component & University of Cape Town, Cape Town, South Africa
| | - Christine Brostjan
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johann Wojta
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Core Facilities, Medical University of Vienna, Vienna, Austria
| | - Philipp J Hohensinner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
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12
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Posch F, Niedrist T, Glantschnig T, Firla S, Moik F, Kolesnik E, Wallner M, Verheyen N, Jost PJ, Zirlik A, Pichler M, Balic M, Rainer PP. Left ventricular ejection fraction and cardiac biomarkers for dynamic prediction of cardiotoxicity in early breast cancer. Front Cardiovasc Med 2022; 9:933428. [PMID: 36051281 PMCID: PMC9424929 DOI: 10.3389/fcvm.2022.933428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/13/2022] [Indexed: 11/21/2022] Open
Abstract
Background/Purpose This study aims to quantify the utility of monitoring LVEF, hs-cTnT, and NT-proBNP for dynamic cardiotoxicity risk assessment in women with HER2+ early breast cancer undergoing neoadjuvant/adjuvant trastuzumab-based therapy. Materials and methods We used joint models of longitudinal and time-to-event data to analyze 1,136 echocardiography reports and 326 hs-cTnT and NT-proBNP measurements from 185 women. Cardiotoxicity was defined as a 10% decline in LVEF below 50% and/or clinically overt heart failure. Results Median pre-treatment LVEF was 64%, and 19 patients (10%) experienced cardiotoxicity (asymptomatic n = 12, during treatment n = 19). The pre-treatment LVEF strongly predicted for cardiotoxicity (subdistribution hazard ratio per 5% increase in pre-treatment LVEF = 0.68, 95%CI: 0.48–0.95, p = 0.026). In contrast, pre-treatment hs-cTnT and NT-proBNP were not consistently associated with cardiotoxicity. During treatment, the longitudinal LVEF trajectory dynamically identified women at high risk of developing cardiotoxicity (hazard ratio per 5% LVEF increase at any time of follow-up = 0.36, 95% CI: 0.2–0.65, p = 0.005). Thirty-four patients (18%) developed an LVEF decline ≥ 5% from pre-treatment to first follow-up (“early LVEF decline”). One-year cardiotoxicity risk was 6.8% in those without early LVEF decline and pre-treatment LVEF ≥ 60% (n = 117), 15.9% in those with early LVEF decline or pre-treatment LVEF < 60% (n = 65), and 66.7% in those with early LVEF decline and pre-treatment LVEF < 60% (n = 3), (Gray’s test p < 0.0001). Conclusion Cardiotoxicity risk is low in two thirds of women with HER2+ early breast cancer who have pre-treatment LVEF ≥ 60% and no early LVEF decline > 5% during trastuzumab-based therapy. The longitudinal LVEF trajectory but not hs-cTnT or NT-proBNP allows for a dynamic assessment of cardiotoxicity risk in this setting.
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Affiliation(s)
- Florian Posch
- Division of Haematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Tobias Niedrist
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Theresa Glantschnig
- Division of Cardiology, University Heart Center, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Saskia Firla
- Department of Cardiology, Rhythmology, and Intensive Care Medicine, KRH Klinikum Siloah, Klinikum Region Hannover GmbH, Hanover, Germany
| | - Florian Moik
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ewald Kolesnik
- Division of Cardiology, University Heart Center, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Markus Wallner
- Division of Cardiology, University Heart Center, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Nicolas Verheyen
- Division of Cardiology, University Heart Center, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp J. Jost
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Department of Medicine III, Klinikum rechts der Isar, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Andreas Zirlik
- Division of Cardiology, University Heart Center, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Pichler
- Division of Cardiology, University Heart Center, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Department of Experimental Therapeutics, MD Anderson Cancer Center, Houston, TX, United States
| | - Marija Balic
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Peter P. Rainer
- Division of Cardiology, University Heart Center, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
- *Correspondence: Peter P. Rainer,
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13
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Sanfilippo KM, Moik F, Candeloro M, Ay C, Di Nisio M, Lee AYY. Unanswered questions in cancer-associated thrombosis. Br J Haematol 2022; 198:812-825. [PMID: 35611985 DOI: 10.1111/bjh.18276] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/02/2022] [Accepted: 05/10/2022] [Indexed: 12/25/2022]
Abstract
Cancer-associated venous thromboembolism (VTE) is a leading cause of morbidity and mortality in patients with cancer. Treatment of cancer-associated VTE comes with a heightened risk of anticoagulant-related bleeding that differs by choice of anticoagulant as well as by patient- and disease-specific risk factors. Available data from randomized controlled trials and observational studies in cancer-associated VTE suggest that direct oral anticoagulants are effective, continuing anticoagulation beyond six months is indicated in those with active cancer and that patients who develop 'breakthrough' thrombotic events can be effectively treated. We review the evidence that addresses these key clinical questions and offer pragmatic approaches in individualizing care. While significant investigative efforts over the past decade have made impactful advances, future research is needed to better define the factors that contribute to anticoagulant-related bleeding and VTE recurrence, in order to aid clinical decision-making that improves the care of patients with cancer-associated VTE.
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Affiliation(s)
- Kristen M Sanfilippo
- Division of Hematology, Washington University School of Medicine St. Louis, St. Louis, MO, USA.,Division of Hematology/Oncology, St. Louis Veterans Administration Medical Center, St. Louis, MO, USA
| | - Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Vienna, Austria.,Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry, University 'G. D'Annunzio', Chieti, Italy
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University 'G D'Annunzio', Chieti-Pescara, Italy
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,Systemic Therapy, BC Cancer, Vancouver, BC, Canada
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14
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Moik F, Ay C. Venous and arterial thromboembolism in patients with cancer treated with targeted anti-cancer therapies. Thromb Res 2022; 213 Suppl 1:S58-S65. [DOI: 10.1016/j.thromres.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/21/2021] [Accepted: 01/03/2022] [Indexed: 10/18/2022]
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15
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Englisch C, Königsbrugge O, Moik F, Quehenberger P, Preusser M, Pabinger I, Ay C. PO-03: Antithrombin activity and association with risk of thrombosis and mortality in patients with cancer. Thromb Res 2022. [DOI: 10.1016/s0049-3848(22)00191-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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16
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Troelsen F, Vágó E, Horváth-Puhó E, van Es N, Mulder F, Moik F, Erichsen R, Ay C, Sørensen H. PO-01: KRAS mutation in colorectal cancer and risk of venous thromboembolism: a Danish population-based cohort study. Thromb Res 2022. [DOI: 10.1016/s0049-3848(22)00189-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Riedl JM, Schwarzenbacher E, Moik F, Horvath L, Gantschnigg A, Renneberg F, Posch F, Barth DA, Stotz M, Pichler M, Hatzl S, Fandler-Höfler S, Gressenberger P, Gary T, Jost PJ, Greil R, Ay C, Djanani A, Gerger A, Schlick K. Patterns of Thromboembolism in Patients with Advanced Pancreatic Cancer Undergoing First-Line Chemotherapy with FOLFIRINOX or Gemcitabine/nab-Paclitaxel. Thromb Haemost 2022; 122:633-645. [PMID: 34255340 DOI: 10.1055/a-1548-4847] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Recent advances in prophylactic anticoagulation and antineoplastic treatment for advanced pancreatic cancer (aPC) warrant an updated reassessment of thromboembolic risk in this population. This multicenter retrospective cohort study aims to comprehensively characterize incidence, risk factors, and outcomes of venous (VTE) and arterial thromboembolism (ATE) in homogenously treated patients with aPC. METHODS Four hundred and fifty-five patients with aPC undergoing palliative first-line chemotherapy (Gemcitabine/nab-Paclitaxel (GN) or FOLIRINOX) were included. Primary outcomes were objectively confirmed VTE and/or ATE. RESULTS Over a median follow-up of 26 months, 86 VTE (cumulative incidence: 20.0%; 95% confidence interval [CI]: 16.3-24.0) and 11 ATE events (cumulative incidence: 2.8%; 95% CI: 1.5-4.9) were observed. VTE diagnosis was associated with increased mortality (transition hazard ratio [THR]: 1.59 [95% CI: 1.21-2.09]) and increased risk of cancer progression (THR: 1.47 [95% CI: 1.08-2.01]), while the impact of ATE on mortality was numerically but not statistically significant (THR: 1.85 [95% CI: 0.87-3.94]). The strongest predictor of increased VTE risk was history of cancer-associated VTE (subdistribution hazard ratio [SHR]: 3.29 [95% CI: 2.09-5.18]), while the Khorana score (SHR: 0.78 [0.57-1.06]) failed to predict VTE risk. A history of cerebrovascular disease was associated with markedly increased ATE risk (SHR: 22.05 [95% CI: 6.83-71.22], p < 0.001), especially ischemic stroke. Risk of VTE/ATE did not significantly differ according to type of first-line chemotherapy. CONCLUSION Patients with aPC undergoing palliative first-line chemotherapy with FOLFIRINOX or GN face a high risk for VTE/ATE and its diagnosis is linked to worse clinical outcomes. VTE-risk prediction models have limited ability to sub-stratify thrombotic events in this high-risk scenario.
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Affiliation(s)
- Jakob M Riedl
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Esther Schwarzenbacher
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Moik
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Lena Horvath
- Department of Internal Medicine V: Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Felix Renneberg
- IIIrd Medical Department of Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectious Disease, Salzburg Cancer Research Institute, Paracelsus Medical University, Salzburg, Austria
| | - Florian Posch
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Dominik A Barth
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Stotz
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Pichler
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stefan Hatzl
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Paul Gressenberger
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Gary
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp J Jost
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Richard Greil
- IIIrd Medical Department of Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectious Disease, Salzburg Cancer Research Institute, Paracelsus Medical University, Salzburg, Austria
| | - Cihan Ay
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Angela Djanani
- Department of Internal Medicine I, Gastroenterology, Hepatology, Metabolism and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
| | - Armin Gerger
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Konstantin Schlick
- IIIrd Medical Department of Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectious Disease, Salzburg Cancer Research Institute, Paracelsus Medical University, Salzburg, Austria
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Moik F, Colling M, Mahé I, Jara‐Palomares L, Pabinger I, Ay C. Extended anticoagulation treatment for cancer-associated thrombosis-Rates of recurrence and bleeding beyond 6 months: A systematic review. J Thromb Haemost 2022; 20:619-634. [PMID: 34816583 PMCID: PMC9299994 DOI: 10.1111/jth.15599] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with cancer-associated venous thromboembolism (VTE) are recommended to receive treatment with therapeutic anticoagulation for at least 3-6 months. Little data exist on extended treatment beyond 6 months. OBJECTIVE To comprehensively summarize the best available evidence on incidence of recurrent VTE and major bleeding 6-12 months after the index event in patients with cancer-associated VTE. PATIENTS/METHODS We systematically screened biomedical databases (MEDLINE, Embase, CENTRAL) to identify studies reporting recurrent VTE and/or bleeding events between 6 and 12 months after a diagnosis of cancer-associated VTE. Based on the observed heterogeneity in study design, setting, patient cohort characteristics, anticoagulation strategies, and outcome rates, no overall quantitative estimate of outcome rates was calculated. RESULTS We screened 2597 publications and identified 11 eligible studies matching predefined in-/exclusion criteria, reporting on 3019 patients specifically during the 6- to 12-month period post-index VTE. Overall rates of recurrent VTE in this timeframe varied substantially (1%-12%), with the highest risk observed in the patient subgroup with residual vein thrombosis present at 6 months randomized to receive no anticoagulation (13%-15%). Reported rates of major bleeding between 6 and 12 months were between 2% and 5%. CONCLUSIONS In this systematic review, we provide a comprehensive and structured summary of the best available evidence on recurrence and bleeding risk between 6 and 12 months after cancer-associated VTE. VTE recurrence remains common beyond 6 months and continuation of different anticoagulation strategies has an acceptable safety profile indicated by lower bleeding rates. These findings support guideline recommendations to continue anticoagulation treatment beyond 6 months in patients with active cancer.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IComprehensive Cancer Center ViennaMedical University of ViennaViennaAustria
- Division of OncologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Meaghan Colling
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IComprehensive Cancer Center ViennaMedical University of ViennaViennaAustria
- Division of Intramural Research (M.E.C.)National Heart, Lung, and Blood InstituteNational Institutes of HealthBethesdaMarylandUSA
| | - Isabelle Mahé
- Department of Internal MedicineColombesAPHPHôpital Louis MourierUniversité de ParisParisFrance
- Innovative Therapies in HaemostasisInstitut National de la Sante et de la Recherche Medicale (INSERM)Université de ParisParisFrance
- F‐CRIN INNOVTE NetworkSaint EtienneFrance
| | - Luis Jara‐Palomares
- Respiratory DepartmentMedical Surgical Unit of Respiratory DiseasesHospital Universitario Virgen del RocioSevillaSpain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES)Instituto de Salud Carlos IIIMadridSpain
| | - Ingrid Pabinger
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IComprehensive Cancer Center ViennaMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IComprehensive Cancer Center ViennaMedical University of ViennaViennaAustria
- I. M. Sechenov First Moscow State Medical UniversityMoscowRussia
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Nopp S, Moik F, Klok FA, Gattinger D, Petrovic M, Vonbank K, Koczulla AR, Ay C, Zwick RH. Outpatient Pulmonary Rehabilitation in Patients with Long COVID Improves Exercise Capacity, Functional Status, Dyspnea, Fatigue, and Quality of Life. Respiration 2022; 101:593-601. [PMID: 35203084 DOI: 10.1159/000522118] [Citation(s) in RCA: 81] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 01/03/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND COVID-19 survivors face the risk of long-term sequelae including fatigue, breathlessness, and functional limitations. Pulmonary rehabilitation has been recommended, although formal studies quantifying the effect of rehabilitation in COVID-19 patients are lacking. METHODS We conducted a prospective observational cohort study including consecutive patients admitted to an outpatient pulmonary rehabilitation center due to persistent symptoms after COVID-19. The primary endpoint was change in 6-min walk distance (6MWD) after undergoing a 6-week interdisciplinary individualized pulmonary rehabilitation program. Secondary endpoints included change in the post-COVID-19 functional status (PCFS) scale, Borg dyspnea scale, Fatigue Assessment Scale, and quality of life. Further, changes in pulmonary function tests were explored. RESULTS Of 64 patients undergoing rehabilitation, 58 patients (mean age 47 years, 43% women, 38% severe/critical COVID-19) were included in the per-protocol-analysis. At baseline (i.e., in mean 4.4 months after infection onset), mean 6MWD was 584.1 m (±95.0), and functional impairment was graded in median at 2 (IQR, 2-3) on the PCFS. On average, patients improved their 6MWD by 62.9 m (±48.2, p < 0.001) and reported an improvement of 1 grade on the PCFS scale. Accordingly, we observed significant improvements across secondary endpoints including presence of dyspnea (p < 0.001), fatigue (p < 0.001), and quality of life (p < 0.001). Also, pulmonary function parameters (forced expiratory volume in 1 s, lung diffusion capacity, inspiratory muscle pressure) significantly increased during rehabilitation. CONCLUSION In patients with long COVID, exercise capacity, functional status, dyspnea, fatigue, and quality of life improved after 6 weeks of personalized interdisciplinary pulmonary rehabilitation. Future studies are needed to establish the optimal protocol, duration, and long-term benefits as well as cost-effectiveness of rehabilitation.
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Affiliation(s)
- Stephan Nopp
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Milos Petrovic
- Outpatient Pulmonary Rehabilitation, Therme Wien Med, Vienna, Austria
| | - Karin Vonbank
- Clinical Division of Pulmonology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Andreas R Koczulla
- Department of Pulmonary Rehabilitation, Member of the German Center for Lung Research (DZL), Philipps-University of Marburg, Marburg, Germany.,Institute for Pulmonary Rehabilitation Research, Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ralf Harun Zwick
- Outpatient Pulmonary Rehabilitation, Therme Wien Med, Vienna, Austria.,Ludwig Boltzmann Institute Rehabilitation Research, Vienna, Austria
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Moik F, Prager G, Thaler J, Posch F, Wiedemann S, Schramm T, Englisch C, Mackman N, Pabinger I, Ay C. Hemostatic Biomarkers and Venous Thromboembolism Are Associated With Mortality and Response to Chemotherapy in Patients With Pancreatic Cancer. Arterioscler Thromb Vasc Biol 2021; 41:2837-2847. [PMID: 34470475 DOI: 10.1161/atvbaha.121.316463] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology (F.M., J.T., S.W., T.S., C.E., I.P., C.A.), Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Gerald Prager
- Clinical Division of Oncology (G.P.), Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Johannes Thaler
- Clinical Division of Haematology and Haemostaseology (F.M., J.T., S.W., T.S., C.E., I.P., C.A.), Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Florian Posch
- Division of Haematology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Austria (F.P.)
| | - Sarah Wiedemann
- Clinical Division of Haematology and Haemostaseology (F.M., J.T., S.W., T.S., C.E., I.P., C.A.), Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Theresa Schramm
- Clinical Division of Haematology and Haemostaseology (F.M., J.T., S.W., T.S., C.E., I.P., C.A.), Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Cornelia Englisch
- Clinical Division of Haematology and Haemostaseology (F.M., J.T., S.W., T.S., C.E., I.P., C.A.), Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Nigel Mackman
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill (N.M.)
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology (F.M., J.T., S.W., T.S., C.E., I.P., C.A.), Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology (F.M., J.T., S.W., T.S., C.E., I.P., C.A.), Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria.,I. M. Sechenov First Moscow State Medical University, Russia (C.A.)
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Mir Seyed Nazari P, Berghoff AS, Preusser M, Moik F, Posch F, Ricken G, Riedl J, Hell L, Marosi C, Hainfellner JA, Pabinger I, Ay C. Association of programmed cell death ligand 1 and circulating lymphocytes with risk of venous thromboembolism in patients with glioma. ESMO Open 2021; 5:e000647. [PMID: 32424065 PMCID: PMC7239522 DOI: 10.1136/esmoopen-2019-000647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/12/2020] [Accepted: 03/09/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction The role of the adaptive immune system in the pathophysiology of cancer-associated venous thromboembolism (VTE) has not been investigated in detail. Programmed cell death ligand 1 (PD-L1) is an immune checkpoint molecule responsible for immune evasion in several cancer entities, as expression on tumour cells silences the T cell-mediated immune response. Given the interrelation between inflammation, haemostasis and cancer, we aimed to investigate the association of players of the adaptive immunity (eg, lymphocytes, tumour PD-L1) with risk of VTE in patients with glioma, one of the most prothrombotic cancer types. Methods In this prospective observational single-centre cohort study, patients with newly diagnosed glioma or regrowth after resection were included. Primary endpoint was objectively confirmed VTE. At study inclusion, a blood draw was performed. Tumour PD-L1 expression was assessed via immunohistochemistry. Results In total, 193 patients were included. PD-L1 expression in ≥1% of tumour cells was observed in 20/193 (10.4%) glioma. In multivariable cox-regression analysis, on adjustment for age, sex and WHO grade IV, systemic lymphocyte counts were significantly associated with risk of VTE (HR per 1 G/L increase (95% CI): 1.15 (1.03 to 1.29), p=0.013). In contrast, no significant difference in risk of VTE was found regarding the PD-L1 status: the cumulative 24 months probability of VTE was 17.0% in patients with no PD-L1 and 11.8% in those with PD-L1 expressing tumours (p=0.663). Conclusion In summary, PD-L1 expression was not associated with risk of VTE. Interestingly, peripheral lymphocytes, which are key players in adaptive immunity, were linked to an increased risk of glioma-associated VTE.
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Affiliation(s)
- Pegah Mir Seyed Nazari
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Florian Moik
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Florian Posch
- Division of Oncology, Medical University of Graz, Graz, Austria
| | - Gerda Ricken
- Institute of Neurology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Julia Riedl
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Lena Hell
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Christine Marosi
- Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Johannes A Hainfellner
- Institute of Neurology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria; I M Sechenov First Moscow State Medical University, Moscow, Russian Federation.
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Hisada Y, Garratt K, Maqsood A, Grover S, Kawano T, Cooley B, Erlich J, Moik F, Flick M, Pabinger I, Mackman N, Ay C. OC-11 Plasminogen activator inhibitor 1 enhances venous thrombosis in pancreatic cancer. Thromb Res 2021. [DOI: 10.1016/s0049-3848(21)00153-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Moik F, Makatsariya A, Ay C. Challenging anticoagulation cases: Cancer-associated venous thromboembolism and chemotherapy-induced thrombocytopenia - A case-based review of clinical management. Thromb Res 2021; 199:38-42. [PMID: 33412483 DOI: 10.1016/j.thromres.2020.12.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 12/21/2022]
Abstract
Patients with cancer undergoing chemotherapy are at risk of thrombocytopenia. The co-incidence of cancer-associated venous thromboembolism (VTE) and thrombocytopenia is a frequent complication in patients with cancer. Especially in certain tumour entities at high VTE risk, chemotherapeutic agents with myelosuppressive effects are part of the standard of care. The management of cancer-associated VTE in the setting of chemotherapy-induced thrombocytopenia is challenging, in the absence of evidence from high-quality studies. Thrombocytopenia is associated with both increased risk of recurrent VTE and risk of bleeding during anticoagulation. In this case-based concise review, we aimed at summarizing available literature and expert consensus guidance on the treatment of cancer-associated VTE in patients with chemotherapy-induced thrombocytopenia.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | | | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria; I. M. Sechenov First Moscow State Medical University, Moscow, Russia.
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Nopp S, Moik F, Jilma B, Pabinger I, Ay C. Risk of venous thromboembolism in patients with COVID-19: A systematic review and meta-analysis. Res Pract Thromb Haemost 2020. [PMID: 33043231 DOI: 10.13039/501100002428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is frequently observed in patients with coronavirus disease 2019 (COVID-19). However, reported VTE rates differ substantially. OBJECTIVES We aimed at evaluating available data and estimating the prevalence of VTE in patients with COVID-19. METHODS We conducted a systematic literature search (MEDLINE, EMBASE, World Health Organization COVID-19 database) to identify studies reporting VTE rates in patients with COVID-19. Studies with suspected high risk of bias were excluded from quantitative synthesis. Pooled outcome rates were obtained within a random effects meta-analysis. Subgroup analyses were performed for different settings (intensive care unit [ICU] vs non-ICU hospitalization and screening vs no screening) and the association of d-dimer levels and VTE risk was explored. RESULTS Eighty-six studies (33,970 patients) were identified and 66 (28,173 patients, mean age: 62.6 years, 60.1% men, 19.4% ICU patients) were included in quantitative analysis. The overall VTE prevalence estimate was 14.1% (95% confidence interval [CI], 11.6-16.9), 40.3% (95% CI, 27.0-54.3) with ultrasound screening and 9.5% (95% CI, 7.5-11.7) without screening. Subgroup analysis revealed high heterogeneity, with a VTE prevalence of 7.9% (95% CI, 5.1-11.2) in non-ICU and 22.7% (95% CI, 18.1-27.6) in ICU patients. Prevalence of pulmonary embolism (PE) in non-ICU and ICU patients was 3.5% (95% CI, 2.2-5.1) and 13.7% (95% CI, 10.0-17.9). Patients developing VTE had higher d-dimer levels (weighted mean difference, 3.26 µg/mL; 95% CI, 2.76-3.77) than non-VTE patients. CONCLUSION VTE occurs in 22.7% of patients with COVID-19 in the ICU, but VTE risk is also increased in non-ICU hospitalized patients. Patients developing VTE had higher d-dimer levels. Studies evaluating thromboprophylaxis strategies in patients with COVID-19 are needed to improve prevention of VTE.
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Affiliation(s)
- Stephan Nopp
- Clinical Division of Haematology and Haemostaseology Department of Medicine I Medical University of Vienna Vienna Austria
| | - Florian Moik
- Clinical Division of Haematology and Haemostaseology Department of Medicine I Medical University of Vienna Vienna Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology Medical University of Vienna Vienna Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology Department of Medicine I Medical University of Vienna Vienna Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology Department of Medicine I Medical University of Vienna Vienna Austria
- I.M. Sechenov First Moscow State Medical University (Sechenov University) Moscow Russia
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Nopp S, Moik F, Jilma B, Pabinger I, Ay C. Risk of venous thromboembolism in patients with COVID-19: A systematic review and meta-analysis. Res Pract Thromb Haemost 2020; 4:1178-1191. [PMID: 33043231 PMCID: PMC7537137 DOI: 10.1002/rth2.12439] [Citation(s) in RCA: 300] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/03/2020] [Accepted: 09/21/2020] [Indexed: 12/13/2022] Open
Abstract
Background Venous thromboembolism (VTE) is frequently observed in patients with coronavirus disease 2019 (COVID-19). However, reported VTE rates differ substantially. Objectives We aimed at evaluating available data and estimating the prevalence of VTE in patients with COVID-19. Methods We conducted a systematic literature search (MEDLINE, EMBASE, World Health Organization COVID-19 database) to identify studies reporting VTE rates in patients with COVID-19. Studies with suspected high risk of bias were excluded from quantitative synthesis. Pooled outcome rates were obtained within a random effects meta-analysis. Subgroup analyses were performed for different settings (intensive care unit [ICU] vs non-ICU hospitalization and screening vs no screening) and the association of d-dimer levels and VTE risk was explored. Results Eighty-six studies (33,970 patients) were identified and 66 (28,173 patients, mean age: 62.6 years, 60.1% men, 19.4% ICU patients) were included in quantitative analysis. The overall VTE prevalence estimate was 14.1% (95% confidence interval [CI], 11.6-16.9), 40.3% (95% CI, 27.0-54.3) with ultrasound screening and 9.5% (95% CI, 7.5-11.7) without screening. Subgroup analysis revealed high heterogeneity, with a VTE prevalence of 7.9% (95% CI, 5.1-11.2) in non-ICU and 22.7% (95% CI, 18.1-27.6) in ICU patients. Prevalence of pulmonary embolism (PE) in non-ICU and ICU patients was 3.5% (95% CI, 2.2-5.1) and 13.7% (95% CI, 10.0-17.9). Patients developing VTE had higher d-dimer levels (weighted mean difference, 3.26 µg/mL; 95% CI, 2.76-3.77) than non-VTE patients. Conclusion VTE occurs in 22.7% of patients with COVID-19 in the ICU, but VTE risk is also increased in non-ICU hospitalized patients. Patients developing VTE had higher d-dimer levels. Studies evaluating thromboprophylaxis strategies in patients with COVID-19 are needed to improve prevention of VTE.
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Affiliation(s)
- Stephan Nopp
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Florian Moik
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Bernd Jilma
- Department of Clinical PharmacologyMedical University of ViennaViennaAustria
| | - Ingrid Pabinger
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
- I.M. Sechenov First Moscow State Medical University (Sechenov University)MoscowRussia
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Fuereder T, Berghoff AS, Heller G, Haslacher H, Perkmann T, Strassl R, Berger JM, Puhr HC, Kreminger J, Moik F, Schubert L, Starzer AM, Steindl A, Winkler S, Preusser M, Tobudic S. SARS-CoV-2 seroprevalence in oncology healthcare professionals and patients with cancer at a tertiary care centre during the COVID-19 pandemic. ESMO Open 2020; 5:e000889. [PMID: 32878898 PMCID: PMC7470513 DOI: 10.1136/esmoopen-2020-000889] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/05/2020] [Accepted: 08/08/2020] [Indexed: 02/06/2023] Open
Abstract
Background During the COVID-19 outbreak, healthcare professionals (HCP) are at the frontline of clinical management and at increased risk for infection. The SARS-CoV-2 seroprevalence of oncological HCP and their patients has significant implications for oncological care. Methods HCP and patients with cancer at the Division of Oncology, Medical University of Vienna were included between 21 March and 4 June and tested for total antibodies against SARS-CoV-2 employing the Roche Elecsys Anti-SARS-CoV-2 immunoassay. Reactive samples were confirmed or disproved by the Abbott SARS-CoV-2 IgG test. Additionally, a structured questionnaire regarding basic demographic parameters, travel history and COVID-19-associated symptoms had to be completed by HCP. Results 146 subjects (62 HCP and 84 patients with cancer) were enrolled. In the oncological HCP cohort, 20 (32.3%) subjects were medical oncologists, 28 (45.2%) nurses at our ward and 14 (22.6%) fulfil other functions such as study coordinators. In the patient cohort, most individuals are on active anticancer treatment (96.4%). 26% of the HCP and 6% of the patients had symptoms potentially associated with COVID-19 since the end of February 2020. However, only in 2 (3.2%) HCP and in 3 (3.6%) patients, anti-SARS-Cov-2 total antibodies were detected. The second assay for anti-SARS-Cov-2 IgG antibodies confirmed the positive result in all HCP and in 2 (2.4%) patients, suggesting an initial assay’s unspecific reaction in one case. In individuals with a confirmed test result, an active COVID-19 infection was documented by a positive SARS-CoV-2 RNA PCR test. Conclusion Specific anti-SARS-CoV-2 antibodies were found solely in persons after a documented SARS-CoV-2 viral infection, thus supporting the test methods’ high sensitivity and specificity. The low prevalence of anti-SARS-CoV-2 antibodies in our cohorts indicates a lack of immunity against SARS-CoV-2. It highlights the need for continued strict safety measures to prevent uncontrolled viral spread among oncological HCPs and patients with cancer.
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Affiliation(s)
- Thorsten Fuereder
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anna Sophie Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Gerwin Heller
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Perkmann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Robert Strassl
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Julia Maria Berger
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Hannah Christina Puhr
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Judith Kreminger
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Lorenz Schubert
- Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Ariane Steindl
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Stefan Winkler
- Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Selma Tobudic
- Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria.
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Moik F, van Es N, Posch F, Di Nisio M, Fuereder T, Preusser M, Pabinger I, Ay C. Gemcitabine and Platinum-Based Agents for the Prediction of Cancer-Associated Venous Thromboembolism: Results from the Vienna Cancer and Thrombosis Study. Cancers (Basel) 2020; 12:cancers12092493. [PMID: 32899157 PMCID: PMC7564761 DOI: 10.3390/cancers12092493] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Certain chemotherapy agents (gemcitabine, platinum-based agents) have been suggested to increase the risk of venous thromboembolism in cancer patients. Our aim was to evaluate, whether treatment with these agents can be used to better predict the risk of cancer-associated venous thromboembolism. Within a prospective observational cohort study, including 1409 patients, we found that treatment with gemcitabine and/or platinum-based agents is only of limited value in predicting the risk of venous thromboembolism beyond known risk factors included in an established risk prediction model (tumor type, blood levels of D-dimer). These findings suggest that a large part of the observed rate of venous thromboembolism in patients treated with these agents might be related to the underlying thrombotic risk rather than the agent itself. Abstract Gemcitabine and platinum-based agents could increase the risk of venous thromboembolism (VTE) in patients with cancer. We evaluated the additive predictive utility of these agents towards cancer-associated VTE beyond a recently developed and externally validated clinical prediction model, which was based on tumor entity and continuous D-dimer levels. Analysis was performed in the derivation cohort of this model, obtained from the Vienna Cancer and Thrombosis Study (CATS), a prospective observational cohort study (n = 1409). Patients were followed for the occurrence of VTE for a maximum of two years. Competing-risk analysis was performed to obtain cumulative incidences and to conduct between-group comparisons of VTE risk. Cumulative two-year incidences of VTE were not elevated with gemcitabine treatment (10.2% vs. 7.5%, p = 0.148), whereas they were higher for platinum-based therapy (11.6% vs. 5.9%, p < 0.001). In a multivariable analysis, adjusting for tumor site category and D-dimer, gemcitabine was not associated with increased risk of VTE (subdistribution hazard ratio (SHR) 0.82, 95% confidence interval (CI) 0.53–1.28, p = 0.390), whereas platinum-based therapy predicted for a numerically increased VTE risk (SHR 1.44, 95% CI 0.96–2.17, p = 0.080). Similar results were obtained in a sensitivity analysis (updated cohort, n = 1870). Our findings suggest limited additional value of chemotherapy for the prediction of cancer-associated VTE, beyond a validated clinical prediction model.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (F.M.); (I.P.)
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Academic Medical Center, 1105 Amsterdam, The Netherlands;
| | - Florian Posch
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria;
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University G. D’Annunzio, 66100 Chieti, Italy;
| | - Thorsten Fuereder
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (T.F.); (M.P.)
| | - Matthias Preusser
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (T.F.); (M.P.)
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (F.M.); (I.P.)
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (F.M.); (I.P.)
- I. M. Sechenov First Moscow State Medical University, 119146 Moscow, Russia
- Correspondence: ; Tel.: +43-1-40400-44100
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Starzer A, Kreminger J, Berger J, Moik F, Rauchwarter M, Mayer J, Haselboeck H, Heller G, Preusser M, Berghoff A. 1877P Fatigue changes according to systemic therapy type in patients with advanced solid cancer. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.1524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Moik F, Chan WS, Wiedemann S, Höller C, Tuchmann F, Aretin MB, Füreder T, Zöchbauer-Müller S, Preusser M, Pabinger I, Ay C. 1824P Incidence, risk factors and clinical outcome of venous and arterial thromboembolism in patients treated with immune-checkpoint inhibitors. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.1471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Riedl J, Posch F, Horvath L, Gantschnigg A, Renneberg F, Schwarzenbacher E, Moik F, Barth D, Stotz M, Schaberl-Moser R, Pichler M, Stöger H, Greil R, Djanani A, Schlick K, Gerger A. 1530P Gemcitabine/nab-paclitaxel versus (modified) FOLFIRINOX for palliative first-line treatment of advanced pancreatic cancer: A propensity score analysis. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.2013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Mollnar S, Pondorfer P, Kasparek AK, Reinisch S, Moik F, Stotz M, Halm M, Szkandera J, Terbuch A, Eisner F, Gerger A, Kapp KS, Partl R, Vasicek S, Weiland T, Pichler M, Stöger H, Thurnher D, Posch F. Decrease in treatment intensity predicts worse outcome in patients with locally advanced head and neck squamous cell carcinoma undergoing radiochemotherapy. Clin Transl Oncol 2020; 23:543-553. [PMID: 32671728 PMCID: PMC7936960 DOI: 10.1007/s12094-020-02447-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 07/02/2020] [Indexed: 12/30/2022]
Abstract
Purpose Radiochemotherapy (RCT) is an effective standard therapy for locally advanced head and neck squamous cell carcinoma (LA-HNSCC). Nonetheless, toxicity is common, with patients often requiring dose modifications. Methods To investigate associations of RCT toxicities according to CTCAE version 5.0 and subsequent therapy modifications with short- and long-term treatment outcomes, we studied all 193 patients with HNSCC who received RCT (70 Gy + platinum agent) at an academic center between 03/2010 and 04/2018. Results During RCT, 77 (41%, 95% CI 34–49) patients developed at least one ≥ grade 3 toxicity, including seven grade 4 and 3 fatal grade 5 toxicities. The most frequent any-grade toxicities were xerostomia (n = 187), stomatitis (n = 181), dermatitis (n = 174), and leucopenia (n = 98). Eleven patients (6%) had their radiotherapy schedule modified (mean radiotherapy dose reduction = 12 Gy), and 120 patients (64%) had chemotherapy modifications (permanent discontinuation: n = 67, pause: n = 34, dose reduction: n = 7, change to other chemotherapy: n = 10). Objective response rates to RCT were 55% and 88% in patients with and without radiotherapy modifications (p = 0.003), and 84% and 88% in patients with and without chemotherapy modifications (p = 0.468), respectively. Five-year progression-free survival estimates were 20% and 50% in patients with and without radiotherapy modifications (p = < 0.001), and 53% and 40% in patients with and without chemotherapy modifications (p = 0.88), respectively. Conclusions Reductions of radiotherapy dose were associated with impaired long-term outcomes, whereas reductions in chemotherapy intensity were not. This suggests that toxicities during RCT should be primarily managed by modifying chemotherapy rather than radiotherapy. Electronic supplementary material The online version of this article (10.1007/s12094-020-02447-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Mollnar
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - P Pondorfer
- Division of General Otorhinolaryngology, Head and Neck Surgery, Department of Otorhinolaryngology; Comprehensive Cancer Center Graz, Medical University of Graz, Graz, Austria
| | - A-K Kasparek
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - S Reinisch
- Division of General Otorhinolaryngology, Head and Neck Surgery, Department of Otorhinolaryngology; Comprehensive Cancer Center Graz, Medical University of Graz, Graz, Austria
| | - F Moik
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - M Stotz
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - M Halm
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - J Szkandera
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - A Terbuch
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - F Eisner
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - A Gerger
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- Center for Biomarker Research in Medicine (CBmed), Graz, Austria
| | - K S Kapp
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center Graz, Medical University of Graz, Graz, Austria
| | - R Partl
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center Graz, Medical University of Graz, Graz, Austria
| | - S Vasicek
- Division of General Otorhinolaryngology, Head and Neck Surgery, Department of Otorhinolaryngology; Comprehensive Cancer Center Graz, Medical University of Graz, Graz, Austria
| | - T Weiland
- Division of General Otorhinolaryngology, Head and Neck Surgery, Department of Otorhinolaryngology; Comprehensive Cancer Center Graz, Medical University of Graz, Graz, Austria
| | - M Pichler
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- Research Unit "Non-Coding RNAs and Genome Editing in Cancer", Medical University of Graz, Graz, Austria
- Department of Experimental Therapeutics, MD Anderson Cancer Center, Houston, TX, USA
| | - H Stöger
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - D Thurnher
- Division of General Otorhinolaryngology, Head and Neck Surgery, Department of Otorhinolaryngology; Comprehensive Cancer Center Graz, Medical University of Graz, Graz, Austria
| | - F Posch
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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Moik F, Ay C, Pabinger I. Risk prediction for cancer-associated thrombosis in ambulatory patients with cancer: past, present and future. Thromb Res 2020; 191 Suppl 1:S3-S11. [DOI: 10.1016/s0049-3848(20)30389-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/14/2019] [Accepted: 12/23/2019] [Indexed: 01/29/2023]
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Moik F, Zöchbauer-Müller S, Posch F, Pabinger I, Ay C. Systemic Inflammation and Activation of Haemostasis Predict Poor Prognosis and Response to Chemotherapy in Patients with Advanced Lung Cancer. Cancers (Basel) 2020; 12:cancers12061619. [PMID: 32570944 PMCID: PMC7352812 DOI: 10.3390/cancers12061619] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 12/25/2022] Open
Abstract
Systemic inflammation and activation of haemostasis are common in patients with lung cancer. Both conditions support tumour growth and metastasis. Therefore, inflammatory and haemostatic biomarkers might be useful for prediction of survival and therapy response. Patients with unresectable/metastatic lung cancer initiating 1st-line chemotherapy (n = 277, 83% non-small cell lung cancer) were followed in a prospective observational cohort study. A comprehensive panel of haemostatic biomarkers (D-dimer, prothrombin fragment 1+2, soluble P-selectin, fibrinogen, coagulation factor VIII, peak thrombin generation), blood count parameters (haemoglobin, leucocytes, thrombocytes) and inflammatory markers (neutrophil-lymphocyte ratio, lymphocyte-monocyte ratio, platelet-lymphocyte ratio, C-reactive protein) were measured at baseline. We assessed the association of biomarkers with mortality, progression-free-survival (PFS) and disease-control-rate (DCR). A biomarker-based prognostic model was derived. Selected inflammatory and haemostatic biomarkers were strong and independent predictors of mortality and therapy response. The strongest predictors (D-dimer, LMR, CRP) were incorporated in a unified biomarker-based prognostic model (1-year overall-survival (OS) by risk-quartiles: 79%, 69%, 51%, 24%; 2-year-OS: 53%, 36%, 23%, 8%; log-rank p < 0.001). The biomarker-based model further predicted shorter PFS and lower DCR. In conclusion, inflammatory and haemostatic biomarkers predict poor prognosis and treatment-response in patients with advanced lung cancer. A biomarker-based prognostic score efficiently predicts mortality and disease progression beyond clinical characteristics.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, 1190 Vienna, Austria; (F.M.); (I.P.)
| | - Sabine Zöchbauer-Müller
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, 1190 Vienna, Austria;
| | - Florian Posch
- Clinical Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria;
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, 1190 Vienna, Austria; (F.M.); (I.P.)
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, 1190 Vienna, Austria; (F.M.); (I.P.)
- I. M. Sechenov First Moscow State Medical University, 119146 Moscow, Russia
- Correspondence:
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Moik F, Posch F, Zielinski C, Pabinger I, Ay C. Direct oral anticoagulants compared to low-molecular-weight heparin for the treatment of cancer-associated thrombosis: Updated systematic review and meta-analysis of randomized controlled trials. Res Pract Thromb Haemost 2020; 4:550-561. [PMID: 32548553 PMCID: PMC7292654 DOI: 10.1002/rth2.12359] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 12/14/2022] Open
Abstract
Background Low‐molecular‐weight‐heparins (LMWHs) have been established for the treatment of cancer‐associated venous thromboembolism (VTE). Recently published randomized controlled trials (RCTs) have compared direct oral anticoagulants (DOACs) with LMWHs. The aim of this systematic review and meta‐analysis was to evaluate efficacy and safety of DOACs versus LMWHs and update the evidence for treatment of VTE in cancer. Methods Biomedical databases were screened for RCTs evaluating DOACs for cancer‐associated VTE. Primary efficacy and safety outcomes of this meta‐analysis were recurrent VTE and major bleeding at 6 months. Secondary outcomes comprised clinically relevant nonmajor bleeding (CRNMB), major gastrointestinal (GI) and genitourinary bleeding, mortality, fatal bleeding/pulmonary embolism, and treatment discontinuation rate. We performed prespecified subgroup analyses. Pooled relative risk (RR) and 95% confidence intervals (CIs) were obtained by the Mantel‐Haenszel method within a random‐effect model. Results We screened 759 articles and included 4 RCTs (n = 2894). DOACs significantly reduced recurrent VTEs compared to LMWHs (5.2% vs 8.2%; RR, 0.62 [95% CI, 0.43‐0.91]), but were associated with a nonsignificant increase in major bleedings (4.3% vs 3.3%; RR, 1.31 [95% CI, 0.83‐2.08]) and a significant increase in CRNMB (10.4% vs 6.4%; RR, 1.65 [95% CI, 1.19‐2.28]). Mortality risks were comparable between groups (RR, 0.99 [95% CI, 0.83‐1.18]). Preterm treatment discontinuation was less common with DOACs (RR, 0.88 [95% CI, 0.81‐0.96]). Major bleeding was more frequent in patients with GI cancer treated with DOACs (RR, 2.30 [95% CI, 1.08‐4.88]). Conclusion In patients with cancer‐associated VTE, DOACs are more effective in preventing recurrent VTE compared to LMWH. However, risk of bleeding is increased with DOACs, especially in patients with GI cancer.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology Department of Medicine I Comprehensive Cancer Center Vienna Medical University of Vienna Vienna Austria
| | - Florian Posch
- Division of Oncology Department of Internal Medicine Comprehensive Cancer Center Graz Medical University of Graz Graz Austria
| | - Christoph Zielinski
- Vienna Cancer Center Vienna Hospital Association and Medical University Vienna Vienna Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology Department of Medicine I Comprehensive Cancer Center Vienna Medical University of Vienna Vienna Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology Department of Medicine I Comprehensive Cancer Center Vienna Medical University of Vienna Vienna Austria
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Abstract
In this concise review, we discuss some common clinical challenges in the management of patients with cancer-associated venous thromboembolism (VTE), a frequent complication in patients with cancer that increases morbidity and mortality. While direct oral anticoagulants (DOACs) have been established in clinical practice for anticoagulation in patients with VTE without cancer, their efficacy and safety in patients with cancer have not been assessed in randomized controlled trials until recently. The choice of the appropriate anticoagulant agent in the era of DOACs to treat patients with cancer-associated VTE is based on balancing the risk of recurrence against the risk of bleeding, and potential drug-drug interactions. However, the management of patients is challenged by special scenarios such as incidentally diagnosed pulmonary embolism and catheter-related thrombosis, and sometimes complicated by concomitant thrombocytopenia. We provide guidance for management of cancer-associated VTE in different clinical scenarios in a case-based manner and briefly review recent clinical studies and guidelines to explain our approach to management of the cases.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Internal Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Internal Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria.,I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Moik F, Posch F, Grilz E, Scheithauer W, Pabinger I, Prager G, Ay C. Haemostatic biomarkers for prognosis and prediction of therapy response in patients with metastatic colorectal cancer. Thromb Res 2020; 187:9-17. [PMID: 31945589 DOI: 10.1016/j.thromres.2020.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/25/2019] [Accepted: 01/03/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Haemostatic activation and hypercoagulability are frequently observed in patients with metastatic colorectal cancer (mCRC), increase risk of venous thromboembolism (VTE) and have been implicated in tumour proliferation and progression. To date, the association of haemostatic biomarkers with oncologic outcomes including overall survival (OS), progression free survival (PFS) and disease control rate (DCR) is incompletely understood. METHODS Within the framework of the Vienna Cancer and Thrombosis Study, a prospective observational cohort study, we conducted an exploratory analysis to investigate the association of six known biomarkers of haemostasis with oncologic outcomes in 99 patients with mCRC prior to chemotherapy initiation. RESULTS Patients with high levels of factor VIII activity (FVIII), D-dimer, prothrombin fragment 1 + 2 (F1 + 2) and fibrinogen (defined as levels >75th percentile) had significantly shorter median OS than patients with lower levels. Elevation of four biomarkers was associated with mortality in multivariable analysis, adjusting for age, sex, number of metastatic sites and VTE (hazard ratio [95% CI] for death per doubling of levels: FVIII: 2.06 [1.28-3.30]; sP-selectin: 1.55 [1.07-2.24]; D-dimer: 1.40 [1.18-1.65]; F1 + 2: 1.64 [1.10-2.46]). Patients with elevated levels had numerically shorter median PFS across all markers and disease control rate (DCR) was significantly smaller in those with high levels of FVIII and F1 + 2 (adjusted odds ratio [95% CI] for DCR per doubling of levels: 0.23 [0.09-0.62] and 0.36 [0.16-0.82]) compared to patients with lower levels. CONCLUSION Specific elevated haemostatic biomarkers are associated with higher mortality and partially with worse response to chemotherapy in patients with mCRC.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Internal Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Florian Posch
- Division of Oncology, Department of Internal Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, Graz, Austria; Center for Biomarker Research in Medicine (CBmed Ges.m.b.H.), Graz, Austria
| | - Ella Grilz
- Clinical Division of Haematology and Haemostaseology, Department of Internal Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Werner Scheithauer
- Clinical Division of Oncology, Department of Internal Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Internal Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Gerald Prager
- Clinical Division of Oncology, Department of Internal Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Internal Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria; I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
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Abstract
Patients with cancer are at an increased risk of symptomatic venous thromboembolism (VTE). In addition, an increasing number of patients with incidental thromboembolic events have been recorded in clinical practice. Therapeutic anticoagulation is crucial to prevent thrombus progression and reduce risk of recurrence; however, this comes at the price of an increased bleeding risk, which necessitates a personalised approach to choose the most appropriate type of therapy. Over the last decade, low-molecular-weight heparin has been the preferred anticoagulant agent for patients with cancer-associated thrombosis due to better efficacy and similar safety profile compared with vitamin K antagonists. While direct oral anticoagulants (DOAC) have emerged as new option for treatment of VTE in a general population, only limited data have been available specifically for patients with cancer until recently. Randomised, controlled trials have now been published, establishing DOAC as an alternative for the treatment of cancer-associated thrombosis. However, the improvement in the therapeutic armamentarium is accompanied by a number of special considerations. For instance, risk of bleeding is elevated in patients with cancer-associated VTE receiving DOAC, especially in certain tumour types (eg, gastrointestinal), and no guidance exists regarding their use in patients with severe thrombocytopaenia. Furthermore, DOAC are prone to certain drug-drug interactions and their effect might be altered due to nausea and vomiting in patients receiving chemotherapy. Here, we provide guidance on how to treat cancer-associated VTE and how new evidence from randomised controlled trials can be implemented in clinical practice. There are still clinical scenarios where robust evidence is lacking and treatment recommendations are based on extrapolations from other populations or expert opinion only. Therefore, additional research in special subpopulations is needed to optimise management of patients in challenging clinical scenarios.
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Affiliation(s)
- Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria; I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
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Mir Seyed Nazari P, Marosi C, Moik F, Riedl J, Özer Ö, Berghoff AS, Preusser M, Hainfellner JA, Pabinger I, Zlabinger GJ, Ay C. Low Systemic Levels of Chemokine C-C Motif Ligand 3 (CCL3) are Associated with a High Risk of Venous Thromboembolism in Patients with Glioma. Cancers (Basel) 2019; 11:cancers11122020. [PMID: 31847343 PMCID: PMC6966639 DOI: 10.3390/cancers11122020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/05/2019] [Accepted: 12/10/2019] [Indexed: 12/16/2022] Open
Abstract
A tight interplay between inflammation and hemostasis has been described as a potential driver for developing venous thromboembolism (VTE). Here, we investigated the association of systemic cytokine levels and risk of VTE in patients with glioma. This analysis was conducted within the prospective, observational Vienna Cancer and Thrombosis Study. Patients with glioma were included at time of diagnosis or progression and were observed for a maximum of two years. Primary endpoint was objectively confirmed VTE. At study entry, a single blood draw was performed. A panel of nine cytokines was measured in serum samples with the xMAP technology developed by Luminex. Results: Overall, 76 glioma patients were included in this analysis, and 10 (13.2%) of them developed VTE during the follow-up. Chemokine C-C motif ligand 3 (CCL3) levels were inversely associated with risk of VTE (hazard ratio [HR] per double increase, 95% confidence interval [CI]: 0.385, 95% CI: 0.161–0.925, p = 0.033), while there was no association between the risk of VTE and serum levels of interleukin (IL)-1β, IL-4, IL-6, IL-8, IL-10, IL-11, tumor necrosis factor (TNF)-α and vascular endothelial growth factor (VEGF), respectively. In conclusion, low serum levels of CCL3 were associated with an increased risk of VTE. CCL3 might serve as a potential biomarker to predict VTE risk in patients with glioma.
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Affiliation(s)
- Pegah Mir Seyed Nazari
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
| | - Christine Marosi
- Division of Oncology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (C.M.); (A.S.B.); (M.P.)
| | - Florian Moik
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
| | - Julia Riedl
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
| | - Öykü Özer
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
| | - Anna Sophie Berghoff
- Division of Oncology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (C.M.); (A.S.B.); (M.P.)
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (C.M.); (A.S.B.); (M.P.)
| | - Johannes A. Hainfellner
- Institute of Neurology and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria;
| | - Ingrid Pabinger
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
| | - Gerhard J. Zlabinger
- Institute of Immunology, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Cihan Ay
- Division of Hematology and Hemostaseology, Department of Medicine I and Comprehensive Cancer Center Vienna, Medical University of Vienna, 1090 Vienna, Austria; (P.M.S.N.); (F.M.); (J.R.); (Ö.Ö.); (I.P.)
- I.M. Sechenov First Moscow State Medical University (Sechenov University), 119146 Moscow, Russia
- Correspondence:
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Posch F, Glantschnig T, Firla S, Smolle M, Balic M, Moik F, Stoeger H, Zirlik A, Pichler M, Rainer P. P6237Clinical utility of echocardiographic left-ventricular ejection fraction monitoring for cardiotoxicity risk assessment in patients with HER2+ early breast cancer undergoing trastuzumab-based therapy. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Monitoring left-ventricular ejection fraction (LVEF) is a routinely-practiced strategy to survey patients with breast cancer (BC) towards cardiotoxic treatment effects. However, whether the LVEF as a single measurement or as a trajectory over time is truly sufficient to identify patients at high risk for cardiotoxicity is currently debated.
Purpose
To quantify the prognostic impact of LVEF and its change over time for predicting cardiotoxicity in women with HER2+ early BC.
Methods
We analyzed 1,136 echocardiography reports from 185 HER2+ early BC patients treated with trastuzumab ± chemoimmunoendocrine therapy in the neoadjuvant/adjuvant setting (Table 1). Cardiotoxicity was defined as a 10% decline in LVEF below 50%.
Results
Median baseline LVEF was 64% (25th-75th percentile: 60–69). Nineteen patients (10%) experienced cardiotoxicity (asymptomatic n=12, symptomatic n=7, during treatment n=19, treatment modification/termination n=14), Median time to cardiotoxicity was 6.7 months, and median LVEF decline in patients with cardiotoxicity was 18%. One-year cardiotoxicity risk was 7.6% in the 35 patients with a baseline LVEF≥60% and 24.5% in the 150 patients with a baseline LVEF<60% (Hazard Ratio (HR)=3.45, 95% CI: 1.35–8.75, Figure 1). During treatment, LVEF declined significantly faster in patients who developed cardiotoxicity than in patients without cardiotoxicity (1.3%/month vs. 0.1%/month, p<0.0001). A higher rate of LVEF decrease predicted for higher cardiotoxicity risk (HR per 0.1%/month higher LVEF decrease/month=2.50, 95% CI: 1.31–4.76, p=0.005), and cardiotoxicity risk increased by a factor of 1.7 per 5% absolute LVEF decline from baseline to first follow-up (HR=1.70, 95% CI: 1.30–2.38, p<0.0001). Thirty-six patients (19%) developed an LVEF decline of at least 5% from baseline to first follow-up (“early LVEF decline”). One-year cardiotoxicity risk was 6.8% in those without early LVEF decline and a baseline LVEF≥60% (n=117), 15.7% in those without an early LVEF decline and a baseline LVEF<60% (n=65), and 66.7% in those with an early LVEF decline and a baseline LVEF<60% (n=3), respectively (log-rank p<0.0001).
Table 1. Baseline characteristics Age (years, median [IQR]) 55 [49–65] Estrogen receptor positive (n, %) 124 (67%) Neoadjuvant setting (n, %) 103 (56%)
Figure 1. Risk of Cardiotoxicity.
Conclusion
Both a single LVEF measurement and the rate of LVEF decrease strongly predict cardiotoxicity in early BC patients undergoing HER2-targeted therapy. Routine LVEF monitoring identifies individuals at high risk of cardiotoxicity that may benefit from more sensitive screening techniques such as strain imaging.
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Affiliation(s)
- F Posch
- Medical University of Graz, Department of Internal Medicine, Graz, Austria
| | - T Glantschnig
- Medical University of Graz, Department of Internal Medicine, Graz, Austria
| | - S Firla
- Medical University of Graz, Department of Internal Medicine, Graz, Austria
| | - M Smolle
- Medical University of Graz, Department of Internal Medicine, Graz, Austria
| | - M Balic
- Medical University of Graz, Department of Internal Medicine, Graz, Austria
| | - F Moik
- Medical University of Vienna, Department of Medicine I, Vienna, Austria
| | - H Stoeger
- Medical University of Graz, Department of Internal Medicine, Graz, Austria
| | - A Zirlik
- Medical University of Graz, Department of Internal Medicine, Graz, Austria
| | - M Pichler
- Medical University of Graz, Department of Internal Medicine, Graz, Austria
| | - P Rainer
- Medical University of Graz, Department of Internal Medicine, Graz, Austria
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Mir Seyed Nazari P, Ay C, Preusser M, Riedl J, Marosi C, Moik F, Ricken G, Hainfellner J, Pabinger-Fasching I, Berghoff A. Association of systemic inflammation with local tumour characteristics and survival in glioma patients. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz243.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Mir Seyed Nazari P, Ay C, Marosi C, Moik F, Riedl J, Ricken G, Hainfellner JA, Preusser M, Pabinger I, Berghoff AS. Correlation of systemic and local inflammation with survival prognosis in glioma patients. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.2052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2052 Background: Immune modulating therapies have been a long withstanding treatment approach in glioma. However, gliomas are characterized by a particular absence of tumor infiltrating lymphocytes in the local tumor microenvironment. We aimed to gain insight on the distinct patterns of inflammation associated with survival prognosis in glioma. Methods: Patients were recruited at time of glioma diagnosis or progression in the prospective observational Vienna Cancer and Thrombosis Study (CATS). A single blood draw was performed at study inclusion. PD-L1 expression in the tumor tissue was investigated via immunohistochemistry. Optimal cut-off according to ROC curve was used to assess cut off values for survival analysis. Results: 193 patients with glioma (75.6% glioblastoma (WHO grade IV), 19.7% anaplastic glioma (WHO grade III), and 4.7% diffuse glioma (WHO grade II)) were included. 40/193 (20.7%) glioma had an IDH1 mutation. Membranous PDL1 expression in the tumor tissue was observed in 20/193 (10.4%) patients. 1/20 patient presented with PD-L1 expression and IDH1 mutation ( p = 0.082). PD-L1 significantly correlated with increased monocyte count (median: 0.657 vs. 0.450 [G/L], p = 0.008), higher C-reactive protein (CRP) (0.43 vs. 0.1 [mg/dL], p = 0.005) and higher fibrinogen (379 vs. 303 [mg/dL], p = 0.001). Presence of IDH1 mutation significantly correlated with increased platelet count (303 vs. 232 [G/L], p = 0.001) and lower Neutrophil/Lymphocyte (N/L) ratio (3.34 vs. 5.13, p = 0.016). Higher lymphocyte count ( > 1.484 [G/L], log-rank: p = 0.011), higher platelet count ( > 245.5 [G/L], p = 0.0001), as well as decreased N/L ratio ( < 5.13, p = 0.001) were significantly associated with increased survival prognosis. Conclusions: PD-L1 expression in tumor tissue was associated with markers of systemic inflammation in glioma patients. Systemic inflammation markers furthermore predicted improved survival. Immune modulating therapy approaches might be a promising approach in subgroups of glioma associated with increased baseline interaction of immune system and glioma.
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Affiliation(s)
- Pegah Mir Seyed Nazari
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Christine Marosi
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Florian Moik
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Julia Riedl
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Gerda Ricken
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Matthias Preusser
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Anna Sophie Berghoff
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Moik F, Riedl JM, Winder T, Terbuch A, Rossmann CH, Szkandera J, Bauernhofer T, Kasparek AK, Schaberl-Moser R, Reicher A, Prinz F, Pichler M, Stöger H, Stotz M, Gerger A, Posch F. Benefit of second-line systemic chemotherapy for advanced biliary tract cancer: A propensity score analysis. Sci Rep 2019; 9:5548. [PMID: 30944390 PMCID: PMC6447553 DOI: 10.1038/s41598-019-42069-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 03/21/2019] [Indexed: 02/08/2023] Open
Abstract
Whether 2nd-line-chemotherapy (2LCTX) + best-supportive-care (BSC) benefits patients with advanced biliary tract cancer (aBTC) more than BSC alone is unclear. We therefore conducted a propensity-score-based comparative effectiveness analysis of overall survival (OS) outcomes in 80 patients with metastatic, recurrent, or inoperable aBTC, of whom 38 (48%) were treated with BSC + 2LCTX and 42 (52%) with BSC alone. After a median follow-up of 14.8 months and 49 deaths, the crude 6-, 12-, and 18-month Kaplan-Meier OS estimates were 77%, 53% and 23% in the BSC + 2LCTX group, and 29%, 21%, and 14% in patients in the BSC group (p = 0.0003; Hazard ratio (HR) = 0.36, 95%CI:0.20-0.64, p = 0.001). An inverse-probability-of-treatment-weighted (IPTW) analysis was conducted to rigorously account for the higher prevalence of favorable prognostic variables in the 2LCTX + BSC group. After IPTW-weighting, the favorable association between 2LCTX and OS prevailed (adjusted HR = 0.40, 95%CI: 0.17-0.95, p = 0.037). IPTW-weighted 6-, 12-, and 18-month OS estimates were 77%, 58% and 33% in the BSC + 2LCTX group, and 39%, 28% and 22% in the BSC group (p = 0.037). Moreover, the benefit of 2LCTX was consistent across several clinically-relevant subgroups. Within the limitations of an observational study, these findings support the concept that 2LCTX + BSC is associated with an OS benefit over BSC alone in aBTC.
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Affiliation(s)
- Florian Moik
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- Clinical Division of Haematology & Haemostaseology, Department of Medicine I, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Jakob M Riedl
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Thomas Winder
- Division of Oncology, Department of Internal Medicine II, Academic Teaching Hospital Feldkirch, Carinagasse 47, 6800, Feldkirch, Austria
| | - Angelika Terbuch
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Christopher H Rossmann
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Joanna Szkandera
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Thomas Bauernhofer
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Anne-Katrin Kasparek
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Renate Schaberl-Moser
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Andreas Reicher
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- Research Center for Molecular Medicine (CeMM) of the Austrian Academy of Sciences, Lazarettgasse 14, 1090, Vienna, Austria
| | - Felix Prinz
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Martin Pichler
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, 1901 East Road, Room 3SCR4.3424, Houston, Texas, 77054, USA
| | - Herbert Stöger
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Michael Stotz
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Armin Gerger
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
- Center for Biomarker Research in Medicine (CBmed), Stiftingtalstrasse 5, 8010, Graz, Austria
| | - Florian Posch
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
- Center for Biomarker Research in Medicine (CBmed), Stiftingtalstrasse 5, 8010, Graz, Austria.
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Riedl JM, Posch F, Moik F, Bezan A, Szkandera J, Smolle MA, Kasparek AK, Pichler M, Stöger H, Stotz M, Gerger A. Inflammatory biomarkers in metastatic colorectal cancer: prognostic and predictive role beyond the first line setting. Oncotarget 2017; 8:96048-96061. [PMID: 29221186 PMCID: PMC5707080 DOI: 10.18632/oncotarget.21647] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/08/2017] [Indexed: 12/27/2022] Open
Abstract
Introduction Inflammatory biomarkers are useful prognostic tools in cancer patients. However, the prognostic and predictive value of inflammatory biomarkers beyond the 1st-line setting in metastatic colorectal cancer (mCRC) is unclear. Results In multivariate analysis 1 standard deviation increase in neutrophil-lymphocyte-ratio (NLR) was associated with an 8.5% absolute lower objective-response-rate (ORR) in 1st-line (p<0.0001), 3% lower ORR in 2nd-line (p< 0.0001), and 3% lower ORR in 3rd-line (p=0.24), respectively. Regarding progression free survival (PFS), an increase in the NLR was significantly associated with rising hazard-ratios (HR) over all treatment lines (HR=1.30, p= 0.021 1st-line); (HR=1.37, p<0.0001 2nd-line); (HR=1.44, p=0.042 3rd-line). The platelet-lymphocyte-ratio (PLR) was associated with 6-month PFS over all three treatment lines. Higher C-reactive-protein (CRP) predicted for worse PFS in the first two chemotherapy lines and in best supportive care (BSC). (HR=1.49 (p<0.0001 1st-line); HR=1.25 (p=0.007 2nd-line); HR=1.09 (95%CI 0.81–1.48, p=0.552 3rd-line and HR=1.43 (p= 0.002 in BSC)). Methods Two-hundred-fifty-eight patients with mCRC undergoing palliative chemo(immuno-)therapy were retrospectively included. Primary endpoints were 6-month PFS and ORR during 1st-line, 2nd-line, and 3rd-line treatment, and 6-month overall survival during BSC. Conclusion This study shows that inflammatory biomarkers are useful predictors of disease outcome and treatment response over several treatment lines in mCRC patients.
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Affiliation(s)
- Jakob Michael Riedl
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Florian Posch
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Florian Moik
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Angelika Bezan
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Joanna Szkandera
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Maria Anna Smolle
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Anne-Katrin Kasparek
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Martin Pichler
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria.,Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77054, USA
| | - Herbert Stöger
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Michael Stotz
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Armin Gerger
- Division of Clinical Oncology, Department of Medicine, Comprehensive Cancer Center Graz, Medical University of Graz, 8036 Graz, Austria.,Center for Biomarker Research in Medicine, 8010 Graz, Austria
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Riedl JM, Posch F, Bezan A, Moik F, Smolle MA, Szkandera J, Pichler M, Stoger H, Stotz M, Gerger A. Inflammatory biomarkers as independent predictive and prognostic markers in metastatic colon cancer patients over several treatment lines. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e15084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e15084 Background: The aim of this study is to quantify the value of the inflammatory biomarkers neutrophil/lymphocyte ratio (NLR), lymphocyte/monocyte ratio (LMR), platelet/lymphocyte ratio (PLR), C-reactive protein (CRP) level and the advanced lung cancer inflammation index (ALI) as predictive and prognostic markers for treatment and survival outcomes over the first three chemotherapy lines in metastatic colorectal cancer (mCRC) patients. Methods: 258 patients with mCRC undergoing palliative chemo(immuno-)therapy were included in this retrospective study. Primary endpoints were 6-month progression free survival (PFS) and overall response rate (ORR) during 1st-line, 2nd-line, and 3rd-line treatment, and 6-month OS during best supportive care. Results: In multivariable analysis adjusting for polychemotherapy, 1 standard deviation (SD) increase in NLR was associated with a 8.5% absolute lower ORR in first line (95%CI: 11-7, p < 0.0001), 3% lower ORR in second line (4-2, p < 0.0001), and 3% lower ORR in third line (8-2, p = 0.24), respectively. The other inflammatory markers were not significantly associated with ORR. Regarding PFS, a higher NLR was consistently associated with higher risk of progression or death across all treatment lines, with rising hazard ratios (HR) over treatment lines (HR 1.30, p = 0.021 first line); (HR 1.37, p < 0.0001 second line); (HR 1.44 , p = 0.042 third line). The PLR was associated with 6 month PFS over all lines. (HR 1.43 (95%CI 1.09 – 1.88, p = 0.009 first line); (HR1.67 (95%CI 1.34 – 2.09, p < 0.0001 second line) and (HR 1.43 (95%CI 1.04 – 1.98, p = 0.029 in third line)) For CRP, the prognostic association was significant in the first two chemotherapy lines and in case of BSC. (HR 1.49 (95%CI 1.23 – 1.80, p < 0.0001 first line); (HR1.25 (95%CI 1.06 – 1.47, p = 0.007 second line); (HR 1.09 (95%CI 0.81 – 1.48, p = 0.552 third line and HR 1.43 (1.15 – 1-79, p = 0.002 in BSC)). More detailed results concerning the other biomarkers will be presented at the meeting. Conclusions: Our data demonstrate that inflammatory biomarkers are important and independent indicators of response to antineoplastic chemotherapy, relevant not only in first, but also in later treatment lines.
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Affiliation(s)
- Jakob M. Riedl
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Posch
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Angelika Bezan
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Moik
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Maria Anna Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Joanna Szkandera
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Pichler
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Herbert Stoger
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Stotz
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Armin Gerger
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Moik F, Riedl JM, Winder T, Bezan A, Rossmann C, Szkandera J, Kasparek AK, Schaberl-Moser R, Pichler M, Stoger H, Stotz M, Gerger A, Posch F. Benefit of second-line chemotherapy for advanced biliary tract cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e15621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e15621 Background: Second-line chemotherapy (2LCTX) is increasingly applied in patients (pts) with advanced biliary tract cancer (aBTC), although no randomized trial has so far demonstrated the benefit of this intervention over best supportive care (BSC) alone. In the absence of randomized data, we thus conducted a comparative effectiveness analysis of survival outcomes in aBTC pts treated with BSC±2LCTX. Methods: In this single-center cohort study, we retrospectively included 80 pts with metastatic, recurrent, or inoperable aBTC who completed 1st-line CTX at our department between 2003 and 2016. Thirty-eight of these pts (48%) received 2LCTX+BSC (Fluoropyrimidine (FP) mono: n = 26 (68%), FP-based combination CTX: n = 9 (24%), Others: n = 3 (8%)). Primary endpoint was 18-month overall survival (OS). An inverse-probability-of-treatment-weighted analysis (IPTW) was implemented to rigorously account for imbalances in prognostic variables between the two study groups. Results: During a median follow-up of 14.8 months, we observed 49 deaths. Six-month, 12-month, and 18-month OS estimates were 77%, 53% and 23% in the BSC+2LCTX group, and 29%, 21%, and 14% in patients in the BSC group, for a univariable hazard ratio (HR) for OS of 0.36 (95%CI: 0.20-0.64, p = 0.001). However, pts receiving 2LCTX+BSC had a significantly higher prevalence of favorable prognostic variables, such as a higher Karnofsky Index (p = 0.0001), lower serum bilirubin (p = 0.03), higher hemoglobin (p = 0.002), and higher serum albumin (p = 0.0007). After careful adjustment for these imbalances using IPTW, 2LCTX+BSC was not associated with an OS benefit over BSC alone (Adjusted HR = 0.62, 95%CI: 0.30-1.29, p = 0.201). In IPTW analysis, 6-, 12-, and 18-month OS were 51%, 33% and 14% in the BSC+2LCTX group, and 35%, 29%, and 19% in patients in the BSC group. The beneficial association of 2LCTX with OS was highly time-dependent, with IPTW HRs of 0.07 (p = 0.002), 0.42 (p = 0.05), and 0.53 (p = 0.11) after 3, 6, and 12 months, respectively. Conclusions: Within the limitations of a non-randomized study, our data support the concept that 2LCTX is associated with a short-term OS benefit in pts with aBTC.
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Affiliation(s)
- Florian Moik
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jakob M. Riedl
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Angelika Bezan
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christopher Rossmann
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Joanna Szkandera
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Anne-Katrin Kasparek
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Renate Schaberl-Moser
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Pichler
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Herbert Stoger
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Stotz
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Armin Gerger
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Posch
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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