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Thrombotic superior vena cava syndrome in cancer patients: data from a single center cohort of 340 consecutive patients
Abstracts / Thrombosis Research 129, Supplement 1 (2012) S155–S194
are downregulated in superficial layers of the endometrium during the secretory phase. In endometrioïd carcinoma, aHS has disappeared, in the vasculature and epithelium, at the invasion front and in tumoral tissue. Conclusion: In secretory endometrium, aHS disappearance suggests that it confers permissiveness to embryo implantation. In endometrioïd cancer, the absence of aHS indicates active tissue plasticity. These data support our hypothesis that aHS is expressed in stable vascular and epithelial walls and downregulated during tumor invasion and tissue remodelling. Further experiments are underways to correlate the mechanisms of implantation and cancer invasion with the disappearance of aHS.
Poster Session 5: Prophylaxis and treatment of thrombosis
PO-51 Asymptomatic venous thrombotic events in ambulatory cancer patients: impact on survival T. Gary 1 , K. Belaj 1 , K. Steidl 1 , M. Pichler 2 , F. Eisner 2 , F. Hafner 1 , H. Froehlich 1 , H. Samonigg 2 , E. Pilger 1 , M. Brodmann 1 1 Division of Angiology and 2 Division of Oncology, Medical University Graz, Austria Introduction: Asymptomatic venous thrombotic events are possible findings in ambulatory cancer patients. Data on the incidence and clinical impact are conflicting. We therefore conducted a prospective study evaluating the occurrence of asymptomatic venous thrombotic events of the lower limbs in ambulatory cancer patients. We further evaluated the influence of these asymptomatic venous thrombotic events on survival during a 9 months follow up period. Material and methods: We included 150 consecutive concerning DVT asymptomatic ambulatory cancer patients. Compression ultrasound was performed by a vascular specialist. In case of pathological findings the patients were treated with low molecular weight heparin (LMWH) due to current guidelines. Results: We were able to find venous thrombotic events in 27 (18%) patients. In 13 patients (8.7%) a superficial venous thrombosis, in 16 patients (10.7%) a deep vein thrombosis was obvious. During the 9 months follow up period the occurrence of a venous thrombotic event at baseline was associated with a 3.9 fold risk for death (HR, 3.9 (1.5-10.3); P=0.004). Conclusion: We conclude that an asymptomatic venous thrombotic event of the lower limbs has a negative effect on survival during a 9 months follow up period despite anticoagulation with LMWH.
PO-52 Thrombotic superior vena cava syndrome in cancer patients: data from a single center cohort of 340 consecutive patients O. Reig, C. Font, I. Victoria, J. Villalta, B. Farrús, J.C. Reverter, D. Tàssies, A. Tuca, P. Gascon Medical Oncology Department, Hospital Clinic de Barcelona, Catalonia, Spain Introduction: Venous thromboembolism (VTE) is a leading cause of dead and morbidity in cancer patients. Thrombotic superior vena cava syndrome (TSVCS) must be taken into account as a form of presentation of the hypercoagulable state associated with cancer. Aim: To evaluate the epidemiology, clinical characteristics and the outcome of cancer patients (pts) with TSVCS. Patients and methods: Prospective observational study enrolling consecutive cancer pts newly diagnosed with VTE (May 2006 to May 2009) carried out in a Medical Oncology Department. The clinical assessment was recorded on a standard data collection sheet and patients were followed-up. For the present study we analyze the frequency, clinical characteristics and outcomes of cancer pts with TSVCS. Results: In eight (2%) out of 340 cancer pts newly diagnosed with VTE the thrombotic event presented as TSVCS (5 men and 3 women; median age of 61 years, range 39 to 71 years). The most frequent tumor was non-small cell lung cancer in 3 patients (37%) followed by bladder cancer in 2 (25%), ovarian cancer in 1, breast cancer in 1 and mediastinal sarcoma in 1. The
S181
TSVCS occurred despite anticoagulant therapy with low molecular weight heparin (LMWH) for a previous thrombotic event in one patient (12%). Six pts (75%) were actively receiving platinum-based chemotherapy for metastatic cancer at the time of developing the TSVCS. The TSVCS was related to the presence of a central venous catheter (CVC) in 4 pts (50%) whereas in the remaining 4 pts (50%) the TSVCS was related to venous compression by mediastinal malignant disease. The clinical picture of TSVCS was progressively established during days in 7 pts but hyperacute in few hours in one patient. Specific theatment for TSVCS was avoided in one patient who had a previous poor general condition due to cancer progression. The CVC was removed in all pts with CVC-related TSVCS. Six pts (75%) were treated with interventional radiology including cavography and stending and 2 pts (25%) received systemic thrombolytic therapy. All pts had a favorable outcome after these invasive interventions and subsequent anticoagulant therapy with LMWH was started and maintained indefinitely without any adverse event related to anticoagulation (mean follow-up of 477 days). There were no deaths directly related to the development and treatment of TSVCS. Conclusions: TSVCS rarely occurs as a form of presentation of VTE in cancer patients. The management with systemic thrombolysis and invasive angioradiological procedures were valid options in our experience. Further prospective studies should be performed in order to better define the optimal treatment in this setting.
PO-53 E-alerts for the prevention of venous thromboembolism in onco-hematological inpatients: pilot evaluation of reasons for physicians’ refusal of pharmacological thromboprophylaxis C. Lazo 1 , R. Lecumberri 1 , S. Varea 1 , A. Alfonso 1 , A. Fernández del Carril 1 , M. Marqués 2 , A. García-Mouriz 3, J.A. Páramo 1 1 Hematology Service, 2 Documentation Service and 3 Informatics Service, University Clinic of Navarra, Pamplona, Spain Background: Most onco-hematological inpatients have a high risk of venous thromboembolism (VTE) and should receive thromboprophylaxis according to current guidelines An electronic alert system (e-alert) developed at our institution has been shown to increase the use of appropriate thromboprophylaxis and reduce the incidence of VTE events during hospitalization, particularly in medical inpatients. However, despite e-alerts many patients do not receive adequate prophylaxis. Aim and methods: Inpatients’ risk of VTE was estimated everyday according to the validated PRETEMED scale. Those patients with a score ≥4 were considered at risk of VTE and an e-alert was sent. The responsible physician was then free to indicate or refuse thromboprophylaxis. The aim of this study was to perform a pilot survey of the reasons for withholding tromboprophylaxis in high risk onco-hematological inpatients despite an e-alert had been sent. Results: Between October and November 2011, 217 patients with solid or hematological cancer were admitted. An e-alert due to high risk of VTE was generated in 148 cases (68%). 65 of these 148 (44%) high-risk patients (mean age 63 years; 54% female) did not receive pharmacological thromboprophylaxis. In 25/65 (38%) cases the absence of thromboprophylaxis was justified by different reasons: thrombocytopenia <50,000/mm3 /coagulopathy, 10 (15.4%); active bleeding, 6 (9.1%); need of invasive procedures, 7 (10.8%); end-of-life care, 2 (3.1%). In 25 cases (38%) no thromboprophylaxis was used because a very short stay was programmed (<48h in most cases). Finally, there were 15 patients (23%) with “unjustified” absence of thromboprophylaxis. In this pilot study no event of VTE during hospitalization in the group without prophylaxis was observed. Conclusions: Despite e-alerts, there are still a significant proportion of onco-hematological inpatients with high risk of VTE who unjustifiably do not receive appropriate thromboprophylaxis. Additional efforts are required to encourage its use in this setting and come closer to the aim of a “thrombosis-free hospital”.
are downregulated in superficial layers of the endometrium during the secretory phase. In endometrioïd carcinoma, aHS has disappeared, in the vasculature and epithelium, at the invasion front and in tumoral tissue. Conclusion: In secretory endometrium, aHS disappearance suggests that it confers permissiveness to embryo implantation. In endometrioïd cancer, the absence of aHS indicates active tissue plasticity. These data support our hypothesis that aHS is expressed in stable vascular and epithelial walls and downregulated during tumor invasion and tissue remodelling. Further experiments are underways to correlate the mechanisms of implantation and cancer invasion with the disappearance of aHS.
Poster Session 5: Prophylaxis and treatment of thrombosis
PO-51 Asymptomatic venous thrombotic events in ambulatory cancer patients: impact on survival T. Gary 1 , K. Belaj 1 , K. Steidl 1 , M. Pichler 2 , F. Eisner 2 , F. Hafner 1 , H. Froehlich 1 , H. Samonigg 2 , E. Pilger 1 , M. Brodmann 1 1 Division of Angiology and 2 Division of Oncology, Medical University Graz, Austria Introduction: Asymptomatic venous thrombotic events are possible findings in ambulatory cancer patients. Data on the incidence and clinical impact are conflicting. We therefore conducted a prospective study evaluating the occurrence of asymptomatic venous thrombotic events of the lower limbs in ambulatory cancer patients. We further evaluated the influence of these asymptomatic venous thrombotic events on survival during a 9 months follow up period. Material and methods: We included 150 consecutive concerning DVT asymptomatic ambulatory cancer patients. Compression ultrasound was performed by a vascular specialist. In case of pathological findings the patients were treated with low molecular weight heparin (LMWH) due to current guidelines. Results: We were able to find venous thrombotic events in 27 (18%) patients. In 13 patients (8.7%) a superficial venous thrombosis, in 16 patients (10.7%) a deep vein thrombosis was obvious. During the 9 months follow up period the occurrence of a venous thrombotic event at baseline was associated with a 3.9 fold risk for death (HR, 3.9 (1.5-10.3); P=0.004). Conclusion: We conclude that an asymptomatic venous thrombotic event of the lower limbs has a negative effect on survival during a 9 months follow up period despite anticoagulation with LMWH.
PO-52 Thrombotic superior vena cava syndrome in cancer patients: data from a single center cohort of 340 consecutive patients O. Reig, C. Font, I. Victoria, J. Villalta, B. Farrús, J.C. Reverter, D. Tàssies, A. Tuca, P. Gascon Medical Oncology Department, Hospital Clinic de Barcelona, Catalonia, Spain Introduction: Venous thromboembolism (VTE) is a leading cause of dead and morbidity in cancer patients. Thrombotic superior vena cava syndrome (TSVCS) must be taken into account as a form of presentation of the hypercoagulable state associated with cancer. Aim: To evaluate the epidemiology, clinical characteristics and the outcome of cancer patients (pts) with TSVCS. Patients and methods: Prospective observational study enrolling consecutive cancer pts newly diagnosed with VTE (May 2006 to May 2009) carried out in a Medical Oncology Department. The clinical assessment was recorded on a standard data collection sheet and patients were followed-up. For the present study we analyze the frequency, clinical characteristics and outcomes of cancer pts with TSVCS. Results: In eight (2%) out of 340 cancer pts newly diagnosed with VTE the thrombotic event presented as TSVCS (5 men and 3 women; median age of 61 years, range 39 to 71 years). The most frequent tumor was non-small cell lung cancer in 3 patients (37%) followed by bladder cancer in 2 (25%), ovarian cancer in 1, breast cancer in 1 and mediastinal sarcoma in 1. The
S181
TSVCS occurred despite anticoagulant therapy with low molecular weight heparin (LMWH) for a previous thrombotic event in one patient (12%). Six pts (75%) were actively receiving platinum-based chemotherapy for metastatic cancer at the time of developing the TSVCS. The TSVCS was related to the presence of a central venous catheter (CVC) in 4 pts (50%) whereas in the remaining 4 pts (50%) the TSVCS was related to venous compression by mediastinal malignant disease. The clinical picture of TSVCS was progressively established during days in 7 pts but hyperacute in few hours in one patient. Specific theatment for TSVCS was avoided in one patient who had a previous poor general condition due to cancer progression. The CVC was removed in all pts with CVC-related TSVCS. Six pts (75%) were treated with interventional radiology including cavography and stending and 2 pts (25%) received systemic thrombolytic therapy. All pts had a favorable outcome after these invasive interventions and subsequent anticoagulant therapy with LMWH was started and maintained indefinitely without any adverse event related to anticoagulation (mean follow-up of 477 days). There were no deaths directly related to the development and treatment of TSVCS. Conclusions: TSVCS rarely occurs as a form of presentation of VTE in cancer patients. The management with systemic thrombolysis and invasive angioradiological procedures were valid options in our experience. Further prospective studies should be performed in order to better define the optimal treatment in this setting.
PO-53 E-alerts for the prevention of venous thromboembolism in onco-hematological inpatients: pilot evaluation of reasons for physicians’ refusal of pharmacological thromboprophylaxis C. Lazo 1 , R. Lecumberri 1 , S. Varea 1 , A. Alfonso 1 , A. Fernández del Carril 1 , M. Marqués 2 , A. García-Mouriz 3, J.A. Páramo 1 1 Hematology Service, 2 Documentation Service and 3 Informatics Service, University Clinic of Navarra, Pamplona, Spain Background: Most onco-hematological inpatients have a high risk of venous thromboembolism (VTE) and should receive thromboprophylaxis according to current guidelines An electronic alert system (e-alert) developed at our institution has been shown to increase the use of appropriate thromboprophylaxis and reduce the incidence of VTE events during hospitalization, particularly in medical inpatients. However, despite e-alerts many patients do not receive adequate prophylaxis. Aim and methods: Inpatients’ risk of VTE was estimated everyday according to the validated PRETEMED scale. Those patients with a score ≥4 were considered at risk of VTE and an e-alert was sent. The responsible physician was then free to indicate or refuse thromboprophylaxis. The aim of this study was to perform a pilot survey of the reasons for withholding tromboprophylaxis in high risk onco-hematological inpatients despite an e-alert had been sent. Results: Between October and November 2011, 217 patients with solid or hematological cancer were admitted. An e-alert due to high risk of VTE was generated in 148 cases (68%). 65 of these 148 (44%) high-risk patients (mean age 63 years; 54% female) did not receive pharmacological thromboprophylaxis. In 25/65 (38%) cases the absence of thromboprophylaxis was justified by different reasons: thrombocytopenia <50,000/mm3 /coagulopathy, 10 (15.4%); active bleeding, 6 (9.1%); need of invasive procedures, 7 (10.8%); end-of-life care, 2 (3.1%). In 25 cases (38%) no thromboprophylaxis was used because a very short stay was programmed (<48h in most cases). Finally, there were 15 patients (23%) with “unjustified” absence of thromboprophylaxis. In this pilot study no event of VTE during hospitalization in the group without prophylaxis was observed. Conclusions: Despite e-alerts, there are still a significant proportion of onco-hematological inpatients with high risk of VTE who unjustifiably do not receive appropriate thromboprophylaxis. Additional efforts are required to encourage its use in this setting and come closer to the aim of a “thrombosis-free hospital”.