ABSTRACT

BACKGROUND: Pulmonary tumour embolism is a rare entity that can arise from a wide variety of neoplasms. It can initially manifest as a pulmonary embolism with right heart failure and be refractory to thrombolytic therapy. Cholangiocarcinoma is a rare malignancy that arises from the epithelium of the biliary tree, representing 3% of all the gastrointestinal malignancies, being the intrahepatic cholangiocarcinoma the second most common liver tumour after hepatocellular carcinoma.

CASE SUMMARY: This case regards a patient that presented to our centre with acute pulmonary embolism, deep vein thrombosis, and unrevealing previous medical history. Imaging studies revealed pulmonary embolism, an ovarian mass, and multiple hepatic hypodensities. Throughout the hospitalization, the patient's haemodynamic state and right heart failure worsened, eventually leading to multi-organ failure and death. Post-mortem evaluation revealed cholangiocarcinoma cells on the pulmonary arteries.

DISCUSSION: Pulmonary tumour embolism is a rare pathology that can present with acute right heart failure. The diagnosis of occult cancer can be challenging, and the appropriate treatment for this entity remains an unexplored subject.

PMID:37457051 | PMC:PMC10347672 | DOI:10.1093/ehjcr/ytad291

14:55

In reply to this message

PubMed articles on: Cancer & VTE/PE

PREDICTORS OF RETRIEVAL AND LONG-TERM MORTALITY IN PATIENTS TREATED WITH INFERIOR VENA CAVA FILTERS

J Vasc Surg Venous Lymphat Disord. 2023 Jul 13:S2213-333X(23)00251-2. doi: 10.1016/j.jvsv.2023.07.005. Online ahead of print.

ABSTRACT

INTRODUCTION: Inferior vena cava filters are a therapeutic resource for the treatment of patients with thromboembolic disease who have a contraindication to full-dose anticoagulation.

OBJECTIVE: To report the retrieval rate and long-term mortality of patients receiving optional inferior vena cava filters. To identify predictors of retrieval and all-cause mortality during follow-up.

METHODS: We conducted a retrospective cohort study including 739 consecutive recipients of optional vena cava filters from January 2002 to December 2021 in two hospitals. Different clinical characteristics and procedure-related variables were included for this analysis. All-cause mortality rate, retrieval rate and its predictors were evaluated in a multivariate analysis.

RESULTS: Fifty three percent of the patients were female. The mean age was 69 ± 15 years. Sixty seven percent presented pulmonary thromboembolism and 43% deep vein thrombosis. A contraindication to anticoagulation was present in nearly 90% of the patients, mainly (47%) related to a surgical procedure. Forty four percent of the patients had active cancer. Follow-up was performed in 94% of the patients, for an average time of 6.08 ± 5.83 years. Long-term mortality was 53%. Cancer [OR 3.60 (95% CI 2.22-5.83)], age [OR 1.03 (95% CI 1.08-1.42)] and deep vein thrombosis [OR 2.01 (95% CI 1.08-1.42)] were identified as independent predictors of mortality. The retrieval rate at follow-up was 33%. As predictors of retrieval, we identified the indication of the filter related to a surgical procedure [OR 4.85 (95% CI 2.54-9.59)], the absence of cancer [OR 2.89 (95% CI 1.45-5.75)] and age [OR 0.98 (95% CI 0.97-0.99)].

CONCLUSIONS: A high long-term mortality was observed. Predictors of death were cancer, age and deep vein thrombosis. One third of the filters implanted were retrieved. Predictors of retrieval were contraindication to surgical-related anticoagulation, absence of cancer, and younger age.

PMID:37453550 | DOI:10.1016/j.jvsv.2023.07.005

14:55

Photo

Not included, change data exporting settings to download.

1200×1200, 39.0 KB

14:55

In reply to this message

PubMed articles on: Cancer & VTE/PE

Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis

Eur Heart J. 2023 Jul 15:ehad417. doi: 10.1093/eurheartj/ehad417. Online ahead of print.

ABSTRACT

AIMS: Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations.

METHODS AND RESULTS: An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10.

CONCLUSION: The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study.

REGISTRATION: PROSPERO ID 89366.

PMID:37452732 | DOI:10.1093/eurheartj/ehad417

14:56

Photo

Not included, change data exporting settings to download.

1200×1200, 39.0 KB

14:56

Photo

Not included, change data exporting settings to download.

1200×1200, 39.0 KB

14:56

In reply to this message

PubMed articles on: Cancer & VTE/PE

Pembrolizumab plus lenvatinib as first-line therapy for advanced non-clear-cell renal cell carcinoma (KEYNOTE-B61): a single-arm, multicentre, phase 2 trial

Lancet Oncol. 2023 Jul 11:S1470-2045(23)00276-0. doi: 10.1016/S1470-2045(23)00276-0. Online ahead of print.

ABSTRACT

BACKGROUND: Immunotherapy-based combinations including pembrolizumab plus lenvatinib are the standard of care for patients with first-line clear-cell renal cell carcinoma, but these combinations are not well characterised in non-clear-cell renal cell carcinoma. We aimed to assess the activity and safety of pembrolizumab plus lenvatinib as a first-line treatment for patients with advanced non-clear-cell renal cell carcinoma.

METHODS: KEYNOTE-B61 is a single-arm, phase 2 trial being conducted at 48 sites (hospitals and cancer centres) in 14 countries (Australia, Canada, France, Hungary, Ireland, Italy, Poland, South Korea, Russia, Spain, Türkiye, Ukraine, the UK, and the USA). Adult patients (aged ≥18 years) with previously untreated stage IV non-clear-cell renal cell carcinoma and a Karnofsky performance status of 70% or higher were eligible for enrolment. All enrolled patients received pembrolizumab 400 mg intravenously every 6 weeks for up to 18 cycles (2 years) plus lenvatinib 20 mg orally once daily or until disease progression, unacceptable toxicity, or withdrawal; lenvatinib could be continued beyond 2 years. The primary endpoint was the proportion of patients with a confirmed objective response as per adjusted Response Evaluation Criteria in Solid Tumours (version 1.1) assessed by independent central review. Activity and safety were analysed in all patients who received at least one dose of study treatment (the as-treated population). This trial is registered with ClinicalTrials.gov (NCT04704219) and is no longer recruiting participants but is ongoing.

FINDINGS: Between Feb 23, 2021, and Jan 21, 2022, 215 patients were screened; 158 were enrolled and received treatment. Median age at baseline was 60 years (IQR 52-69), 112 (71%) of 158 patients were male, 46 (29%) were female, 128 (81%) were White, 12 (8%) were Asian, three (2%) were Black or African American, and 15 (9%) were missing data on race. As of data cutoff (Nov 7, 2022), median study follow-up was 14·9 months (IQR 11·1-17·4). 78 of 158 patients had a confirmed objective response (49%; 95% CI 41-57), including nine (6%) patients with a confirmed complete response and 69 (44%) with a confirmed partial response. Grade 3-4 treatment-related adverse events occurred in 81 (51%) of 158 patients, the most common of which were hypertension (37 [23%] of 158), proteinuria (seven [4%]), and stomatitis (six [4%]). Serious treatment-related adverse events occurred in 31 (20%) of 158 patients. Eight (5%) patients died due to adverse events, none of which was considered related to the treatment by the investigators (one each of cardiac failure, peritonitis, pneumonia, sepsis, cerebrovascular accident, suicide, pneumothorax, and pulmonary embolism).

INTERPRETATION: Pembrolizumab plus lenvatinib has durable antitumour activity in patients with previously untreated advanced non-clear-cell renal cell carcinoma, with a safety profile consistent with that of previous studies. Results from KEYNOTE-B61 support the use of pembrolizumab plus lenvatinib as a first-line treatment option for these patients.

FUNDING: Merck Sharp & Dohme (a subsidiary of Merck & Co, NJ, USA), and Eisai.

PMID:37451291 | DOI:10.1016/S1470-2045(23)00276-0

14:56

In reply to this message

PubMed articles on: Cancer & VTE/PE

Heparin reversal with protamine sulfate after Percutaneous Hepatic Perfusion (PHP): is less more?

Cancer Imaging. 2023 Jul 14;23(1):68. doi: 10.1186/s40644-023-00590-7.

ABSTRACT

PURPOSE: Percutaneous hepatic perfusion (PHP) is a palliative intraarterial therapy for unresectable hepatic malignancies. During PHP, high-dose melphalan is infused via the hepatic artery to saturate tumor in the liver with the chemotherapeutic substance. The venous hepatic blood is filtered by an extracorporeal melphalan specific filtration system. Blood clotting in the extracorporeal filter system is prevented by administering unfractionated heparin (UFH) in high doses, which might be reversed with protamine sulfate after the procedure. Aim of this retrospective two-center-study was to analyze the potential effect of UFH reversal with protamine sulfate on complication rates following PHP.

MATERIALS AND METHODS: All patients receiving PHP treatment between 10/2014 and 04/2021 were classified according to their intraprocedural coagulation management: 92 patients/192 PHP received full UFH reversal with protamine (groupPROTAMINE); 13 patients/21 PHP in groupREDUCED_PROTAMINE received a reduced amount of protamine, and 28 patients/43 PHP did not receive UFH reversal with protamine (groupNO_PROTAMINE). Periinterventional clinical reports, findings and laboratory values were retrospectively evaluated. Complications and adverse events were classified according to Common Terminology Criteria for Adverse Events (CTCAEv5.0).

RESULTS: Thromboembolic events were recorded after 10 PHP procedures (5%) in groupPROTAMINE, six of which (3%) were major events (CTCAE grade 3-5). No (0%) thromboembolic events were recorded in groupREDUCED_PROTAMINE and groupNO_PROTAMINE. Hemorrhagic events were registered after 24 PHP (13%) in groupPROTAMINE, two of which (1%) were major (CTCAE grade 3-4). In groupREDUCED_PROTAMINE, only minor bleeding events were recorded, and one major hemorrhagic event was documented in groupNO_PROTAMINE (2%). There was a significant difference between the percentage of post-interventional thrombopenia in groupPROTAMINE (39%) and groupREDUCED_PROTAMINE (14%) versus groupNO_PROTAMINE (23%) (p=.00024). In groupPROTAMINE one patient suffered from a severe anaphylactic shock after the administration of protamine.

CONCLUSION: Our retrospective study implies that there might be a link between the practice of protamine sulfate administration to reverse the full hemodilutive effect of UFH after PHP and the post-interventional risk of thromboembolic events as well as clinically significant thrombopenia. Our data suggest that the standard use of protamine sulfate after PHP in low-risk patients without clinical signs of active bleeding should be critically re-evaluated.

PMID:37452405 | PMC:PMC10349410 | DOI:10.1186/s40644-023-00590-7

14:56

Photo

Not included, change data exporting settings to download.

1200×1200, 39.0 KB

14:56

Photo

Not included, change data exporting settings to download.

1200×1200, 39.0 KB

14:56

In reply to this message

PubMed articles on: Cancer & VTE/PE

Clinical presentations of acute pulmonary embolism: A retrospective cohort study

Medicine (Baltimore). 2023 Jul 14;102(28):e34224. doi: 10.1097/MD.0000000000034224.

ABSTRACT

We aimed to investigate whether the unusual clinical presentation of pulmonary embolism (PE) varies by the type of provocation. In this retrospective cohort study, we examined the electronic health records (EHR) records of all patients diagnosed with PE (upon presentation or during hospitalization) presented to our tertiary hospital during 2014 to 2019. Inclusion criteria were the diagnosis of acute PE and age above 18 years. Excluded were all patients to whom complete EHR were not available. The primary outcome was the main presenting symptom, categorized by a multidisciplinary consensus expert committee as either typical or atypical of PE. Comorbidities, vital signs, medications and laboratory results on presentations were recorded. 591 patients were included in the final analysis. Dyspnea was significantly less common and hemoptysis and chest pain more common in the unprovoked PE group (35%, 5%, and 25%, respectively) compared with nonmalignant (42.6%, 0%, and 16.3%) and malignancy-associated (47.7%, 0.9%, and 8.2%) PE (Pv = 0.02, 0.002 and 0.001, respectively). No recorded symptoms were the third most common presentation overall, accounting for a significantly (Pv < 0.001) higher proportion of PE patients with malignancy (19%) whereas atypical presentation was the hallmark of patients with nonmalignant provokation (19.7%) (Pv = 0.005). Accounting for multiple potential confounders, the risk of atypical or asymptomatic presentation was higher with lower heart rates (RR = 0.974 95%C.I. [0.957-0.990]) and higher pulse oximetry saturation (RR = 1.114 95%CI [1.034-1.201]). The clinical presentation of PE varies with different types of provoking factors, with atypical presentation most common in nonmalignant provocation and asymptomatic presentation most prevalent in patients with underlying malignancy. Further studies are needed to determine the effect of said variance on long term clinical outcomes.

PMID:37443506 | PMC:PMC10344497 | DOI:10.1097/MD.0000000000034224

14:56

PubMed articles on: Cancer & VTE/PE

The impact of body mass index on oncoplastic breast surgery: A multicenter analysis

J Surg Oncol. 2023 Jul 13. doi: 10.1002/jso.27397. Online ahead of print.

ABSTRACT

BACKGROUND: Obesity has nearly tripled in the last 50 years. During the last decades, oncoplastic breast surgery has become an important choice in the surgical treatment of breast cancer. An association exists between higher body mass index (BMI) and wound complications for major operations, but there is scarce literature on oncoplastic surgery. Hence, our aim was to compare the complication rates among patients who underwent oncoplastic surgery, stratified by BMI.

METHODS: Patient data were analyzed from the National Surgical Quality Improvement Program database (NSQIP) for oncoplastic breast procedures (2005-2020). Patients were stratified according to World Health Organization obesity classifications. Multivariate logistic regression was performed to assess risk factors for complications (overall, operative, and wound-related).

RESULTS: From a total of 6887 patients who underwent oncoplastic surgery, 4229 patients were nonobese, 1380 had Class 1 obesity (BMI: 30 to <352 ), 737 Class 2 obesity (BMI: 35 to <402 ), and 541 Class 3 obesity (BMI: ≥ 40 kg/m2 ). Greater operative time was found according to higher BMI (p < 0.001). Multivariate analysis adjusted for baseline characteristics showed that patients with obesity Class 2 (odds ratio [OR] = 1.51, 95% confidence interval [CI]: 1.03-2.23, p = 0.037) and 3 (OR = 1.87, 95% CI 1.24-2.83, p = 0.003) had increased risk of overall and wound complications compared with Nonobese patients. Comparing obese with nonobese patients, there were no differences in rates of deep SSI, organ/space SSI, pneumonia, reintubation, pulmonary embolism, deep vein thrombosis, urinary tract infection, stroke, bleeding, postoperative sepsis, length of stay, and readmission.

CONCLUSIONS: Oncoplastic surgery is a safe procedure for most patients. However, caution should be exercised when performing oncoplastic surgery for patients with Class 2 or 3 obesity (BMI ≥ 35 kg/m2 ), given there was a higher rate of overall and wound-specific complications, compared with patients who were not obese or had Class 1 obesity.

PMID:37448232 | DOI:10.1002/jso.27397

14:56

In reply to this message

PubMed articles on: Cancer & VTE/PE

High-intensity interval training and thromboembolic events during chemotherapy for testicular cancer: a retrospective analysis from the Body & Cancer cohort

Acta Oncol. 2023 Jun;62(6):666-672. doi: 10.1080/0284186X.2023.2225145. Epub 2023 Jul 14.

ABSTRACT

Background:Men with testicular cancer receiving platinum-based chemotherapy have an increased risk of thromboembolic events, with incidence rates between 8-24%. A recent trial evaluating the effect of high-intensity interval training (HIIT) prematurely closed as three out of nine participants (33%) in the intervention group developed a thromboembolic event. The purpose of this retrospective cohort study was: 1) (primary) to evaluate the incidence of thromboembolic events in men receiving chemotherapy for testicular cancer who had participated in HIIT during a 6-week exercise program (Body & Cancer) 2) to describe the feasibility of this program.Material and methods: Forty men who had participated in at least one HIIT session from February 2007 to February 2020 were included. Electronic medical records were searched for incident thromboembolic events (arterial and venous) during Body & Cancerand up to one-year post-chemotherapy. Attendance, cardiorespiratory fitness (VO2-peak), and upper and lower extremity muscular strength (1 repetition maximum (RM)) were obtained from the Body & Cancerdatabase.Results: One participant developed a thromboembolic event during Body & Cancer. No participants developed a thromboembolic event in the follow-up period. In all, data represent 160 HIIT sessions with a median attendance of eight sessions [range 1-19]. Statistically significant increases in upper and lower extremity strength were observed (8.6 (4.2 to 13.0) and 26.0 (14.9 to 37.0) kg, respectively). No significant increase in cardiorespiratory fitness was found (0.14 (-0.03 to 0.31) l/min).Conclusion: While conclusions on the safety of HIIT cannot be drawn, data from the present study do not support previous findings cautioning avoidance of HIIT due to a possible added risk of thromboembolic events in men receiving platinum-based chemotherapy for testicular cancer. Considering the potential for positive effects on cardiovascular outcomes associated with HIIT, future studies with robust design should be performed in this population to confirm these observations.

PMID:37450654 | DOI:10.1080/0284186X.2023.2225145

14:56

PubMed articles on: Cancer & VTE/PE

Prevalence and outcomes of type 2 myocardial infarction in patients with cancer: A retrospective analysis from the National Inpatient Sample dataset

Int J Cardiol. 2023 Jul 11:131154. doi: 10.1016/j.ijcard.2023.131154. Online ahead of print.