Molecular and clinical conditions associated with venous thromboembolism in oncological patients
The association between cancer and thrombophilia has been known since 1865 since Trousseau described it. However in the last three decades an increased interest has been raised on this issue related to several molecular and condition that are involved in the daily management of oncological patients....
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irk-123456789-1375792018-06-18T03:03:48Z Molecular and clinical conditions associated with venous thromboembolism in oncological patients Micco, P. Di Amitrano, M. Niglio, A. Fontanella, A. Reviews The association between cancer and thrombophilia has been known since 1865 since Trousseau described it. However in the last three decades an increased interest has been raised on this issue related to several molecular and condition that are involved in the daily management of oncological patients. This brief review has been focused on molecular conditions underlying cancer acquired thrombophilia then to further clinical aspects inducing thrombophilia in oncological patients such as surgery, chemotherapy, concomitant medical illness and inherited thrombophilia. Связь между опухолевым процессом и гематогенной тромбофилией известна с 1865 г., когда Trousseau впервые дал ее описание. В последнее время отмечают возрастающий интерес к этой проблеме и связанным с ней молекулярным и клиническим параметрам, которые учитываются при постоянном наблюдении за больными онкологического профиля. Данный короткий обзор литературы посвящен характеристике молекулярных факторов, лежащих в основе тромбофилии, возникающей в процессе развития новообразований, а также другим особенностям клинического течения, индуцирующим тромбофилию у больных онкологического профиля, таким как хирургическое вмешательство, химиотерапия, сопутствующие осложнения и наследственная тромбофилия 2006 Article Molecular and clinical conditions associated with venous thromboembolism in oncological patients / P. Di Micco, M. Amitrano, A. Niglio, A. Fontanella // Experimental Oncology. — 2006. — Т. 28, № 3. — С. 194-197. — Бібліогр.: 32 назв. — англ. 1812-9269 http://dspace.nbuv.gov.ua/handle/123456789/137579 en Experimental Oncology Інститут експериментальної патології, онкології і радіобіології ім. Р.Є. Кавецького НАН України |
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Reviews Reviews Micco, P. Di Amitrano, M. Niglio, A. Fontanella, A. Molecular and clinical conditions associated with venous thromboembolism in oncological patients Experimental Oncology |
| description |
The association between cancer and thrombophilia has been known since 1865 since Trousseau described it. However in the last three decades an increased interest has been raised on this issue related to several molecular and condition that are involved in the daily management of oncological patients. This brief review has been focused on molecular conditions underlying cancer acquired thrombophilia then to further clinical aspects inducing thrombophilia in oncological patients such as surgery, chemotherapy, concomitant medical illness and inherited thrombophilia. |
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Article |
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Micco, P. Di Amitrano, M. Niglio, A. Fontanella, A. |
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Micco, P. Di Amitrano, M. Niglio, A. Fontanella, A. |
| author_sort |
Micco, P. Di |
| title |
Molecular and clinical conditions associated with venous thromboembolism in oncological patients |
| title_short |
Molecular and clinical conditions associated with venous thromboembolism in oncological patients |
| title_full |
Molecular and clinical conditions associated with venous thromboembolism in oncological patients |
| title_fullStr |
Molecular and clinical conditions associated with venous thromboembolism in oncological patients |
| title_full_unstemmed |
Molecular and clinical conditions associated with venous thromboembolism in oncological patients |
| title_sort |
molecular and clinical conditions associated with venous thromboembolism in oncological patients |
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Інститут експериментальної патології, онкології і радіобіології ім. Р.Є. Кавецького НАН України |
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2006 |
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Reviews |
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http://dspace.nbuv.gov.ua/handle/123456789/137579 |
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Molecular and clinical conditions associated with venous thromboembolism in oncological patients / P. Di Micco, M. Amitrano, A. Niglio, A. Fontanella // Experimental Oncology. — 2006. — Т. 28, № 3. — С. 194-197. — Бібліогр.: 32 назв. — англ. |
| series |
Experimental Oncology |
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2025-07-10T02:37:22Z |
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1837225783250124800 |
| fulltext |
194 Experimental Oncology 28, 194–197, 2006 (September)
Venous thromboembolism (VTE) is a multifactorial
disease, which may appear as deep venous throm-
bosis (DVT) of lower or upper limb, abdominal deep
venous thrombosis and/or pulmonary embolism (PE).
Of course, PE represent the most dangerous clinical
manifestation and it may be classified as non-massive
PE or massive PE that may lead to severe impairment
of gas exchange and pulmonary hypertension induc-
ing right ventricular dysfunction and/or heart failure
then to be fatal within the first 30 min of symptom
onset [1].
However, VTE recognizes inherited and acquired
risk factors and cancer is the most common acquired
thrombotic risk factor since Trousseau described this
clinical association for the first time in 1865. On the
other hand oncological patients with concurrent VTE
are more at risk according to the data reported by So-
rensen at al. [2].
Furthermore, during the natural history of onco-
logical disease other thrombotic risk factors may be
involved, so inducing a strong increase of VTE risk for
oncological patients. This short review is focused to
the evaluation of the main thrombotic risk factors in
oncological patients.
CanCer assoCiated thrombophilia
Malignancy usually shows prothrombotic properties
per se related to the release of various prothrombotic
molecules such as tissue factor (TF) and/or cancer
prococoagulant (CP) from malignant cells [3].
CP is cysteine proteinase produced by different
types of malignant cells that may directly activate
clotting factor X without the involvement of clotting VII
pathway [3].
Yet, cancer cells may also express and release TF
their self so inducing an hyperactivation of clotting
cascade via clotting factor VII pathway [3]. More-
over, TF can also be expressed by endothelial cells
or monocytes/macrophages because the involve-
ment of cytokine network related to tumor growth, in
particular, interleukin-1β and tumor necrosis factor α
[3]. Furthermore, also release of clotting factor X by
malignant cells has been rarely described [4].
Other molecular alterations associated with tumor
growth and progression may be related to the involve-
ment of fibrinolytic system. A specific interaction
between cancer cells and extracellular matrix has
been described because an impairment of protease/
antiprotease balance causing an increased injury of
extracellular matrix [5]. This impairment may modify
the ability of cancer cells to the expansion also in the
extracellular matrix so increasing the power of malig-
nant growth and metastasis [5].
The effect of described activities is a cancer
acquired thrombophilia that may also be divided in
subclinical thrombophilia (i. e. hypercoagulable state)
and clinical thrombophilia in which we may recognise
an ongoing thrombotic event (e. g. VTE) [6].
CanCer and hyperCoagulable state
A subclinical hypercoagulable state has been
already described in oncological patients by several
authors in the literature. Several tests, in fact, may
testify the acquired hypercoagulable state present
in cancer such as increased levels of d-dimer, pro-
thrombin fragment 1 + 2 and/or thrombin-antithrombin
complexes [7]. Although, we previously reported the
underlying molecular mechanisms responsible for
cancer acquired thrombophilia, also other conditions
have been described in the literature. Some report, in
fact, described an acquired protein C resistance [8]
and/or increased levels of fibrinogen [9]; on the other
moleCular and CliniCal Conditions assoCiated with
venous thromboembolism in onCologiCal patients
P. Di Micco1, 2, *, M. Amitrano3, A. Niglio4, A. Fontanella1
1Division of Internal Medicine, Buonconsiglio Fatebenefratelli Hospital of Naples, Naples, Italy
2Department of Biochemistry and Medical Biotechnology and CEINGE SCARL,
Federico II University of Naples, Naples, Italy
3Division of Angiology, A.O.R.N. G. Moscati, Avellino, Italy
4IV Division of Internal Medicine, Second University of Naples, Naples, Italy
The association between cancer and thrombophilia has been known since 1865 since Trousseau described it. However in the last
three decades an increased interest has been raised on this issue related to several molecular and condition that are involved in the
daily management of oncological patients. This brief review has been focused on molecular conditions underlying cancer acquired
thrombophilia then to further clinical aspects inducing thrombophilia in oncological patients such as surgery, chemotherapy, con-
comitant medical illness and inherited thrombophilia.
Key Words: cancer, thrombophilia, hypercoagulable state, inherited thrombophilia, chemotherapy.
Received: June 12, 2006.
*Correspondence: E-mail: pdimicco@libero.it
Abbreviations used: CMF — cyclophospamide-methotrexate-
fluoruracil; CP — cancer prococoagulant; CVC — central venous
catheter; DVT — deep venous thrombosis; G-CSF — growth colony
stimulating factors; PaC — port-a-cath; PE — pulmonary embolism;
TF — tissue factor; VTE — venous thromboembolism.
Exp Oncol 2006
28, 3, 194–197
Experimental Oncology 28, 194–197, 2006 (September) 195
hand also hypofibrinolysis due to impaired levels of
plasminogen activator inhibitor type 1 and/or type 2
has been reported [10–11].
A clinical hypercoagulable state may be defined
as the clinical thrombotic manifestation (e. g. VTE)
triggered by cancer acquired thrombophilia. On this
topic we usually may find a venous thromboembolism
but also other clinical manifestation such as arterial
thrombosis [12] or disseminated intravascular coagu-
lation [13] may be detected. However, in the last years
several studies have underlined the association be-
tween cancer and VTE in order to promote also further
studies on thromboprophylaxis of VTE in oncological
patients [14–15]. Moreover, on this topic we should
underline that VTE may appear usually as DVT of lower
limb with following PE, but also unusual site of venous
thrombosis during malignancy was described, such as
abdominal deep vein thrombosis and/or spontaneous
upper limb DVT.
CliniCal Conditions assoCiated
with vte in onCology
Type of cancer. Since Trousseau described for
the first time the association between cancer and
thrombosis, several authors associated particular type
of cancer to thrombotic complication. On this field
Levitan et al. [16] confirmed that such type of cancer
is more at risk of VTE complications such as pancreatic
cancer, ovarian cancer or cancer localised to central
nervous system.
Yet, further study underlined also another interest-
ing aspect of oncological disease such as the staging.
Advanced stage of oncological malignancy have been
more frequently associated with VTE [17] if compared
to early stage of malignancy.
Oncological surgery. Surgical procedures are
the most common known risk factor for VTE. The as-
sociation between major surgery and VTE, in fact, has
been underlined by long time. Yet, surgical approach
is usually related to post-surgical bed rest so add-
ing another thrombotic risk factor. However, on this
topic authors described a more common association
between oncological surgery and VTE if compared to
non-oncological surgery, although double blind ran-
domised trial on these issues are lacking. Of course,
benefits of thromboprophylaxis to prevent VTE for
surgical management are clear for both oncological
and non-oncological major surgery and have been
demonstrated by several studies available in the lite-
rature [18–22].
Chemotherapy and other treatments. VTE has
been already underlined in patients ongoing chemo-
therapy. First studies are available in the literature since
1980 and are focused mainly on patients affected
by breast cancer in particular in advanced stage of
disease [23–24]. In the following years several other
studies focused the role of chemotherapy as additional
risk factor for VTE in particular during treatment of
haematological malignancies.
Furthermore, also specific drugs have been
frequently involved in pathophysiology of acquired
thrombophilia during chemotherapy. A common ex-
perience has been given by chemotherapy for breast
cancer based on CMF regimen. CMF, but also other
chemotherapeutical regimen, showed to reduce the
levels of natural anticoagulant such as protein C and
protein S in particular if associated with administra-
tion of tamoxifen [25]. Tamoxifen and other hormonal
drugs, in fact, associated with chemotherapy, have
been reported by several studies in the literature as
thrombotic risk factors [25].
On the other hand, also growth colony stimulating
factors (G-CSF) to fight chemotherapy-induced neu-
tropenia showed a prothrombotic action [26].
Yet, in the last 10 years also thalidomide has been
frequently associated with thrombotic complica-
tion during chemotherapy, while pathophysiological
mechanisms involved are still the matter of discus-
sion [27].
Central venous catheters and thrombosis.
Central venous catheterisation is actually well estab-
lished procedure in patients affected by malignancy
in order to simplify delivery of several therapies such
as chemotherapy, as blood transfusion and/or blood
products administration, as parenteral nutrition, as
fluids and other medication, in particular if peripheral
venous accesses are lacking.
From this point of view we may distinguish cen-
tral venous catheter (CVC) in central venous line
(e. g. subclavian or jugular veins) or port-a-cath (PaC).
However, since these procedures have been adopted
an increased number of complications such as throm-
bosis and/or infections have been pointed out.
We may distinguish two several types of catheter-
related thrombosis: a sleeve thrombosis on the outside
of central venous catheter or a vascular thrombosis
in which also the vein is involved by the thrombotic
complication of CVC/PaC [28].
For this reason we observed also an increased
incidence of upper limb DVT in the last decades if
compared with previous data available in the literature
in which this kind of venous thrombosis has been con-
sidered rare [29]. From a clinical point of view usually
thrombotic complication of CVC/PaC are DVT of upper
limb with frequent involvement of all the venous axis
(e. g. extended venous thrombosis of axillar-subcla-
vian and internal jugular axis) and this is a relevant
data because subclavian and internal jugular DVT are
frequently associated with PE.
Concomitant medical illness. Several patients
affected by cancer may be affected by further medical
illness that may lead to a further increase of risk of VTE.
In these conditions we should include first of all recent
immobility due to acute medical illness. Of course, im-
mobility of oncological patients may be due to cancer
disease per se, but frequently other conditions such as
side effects of cancer therapies or following medical
illness are present. Recent studies, in fact, underlined
also medical illness, in particular if prolonged bed rest
196 Experimental Oncology 28, 194–197, 2006 (September)
is required, as additional risk factors for VTE in cancer
patients such as severe infections, as heart failure,
as chronic lung injury, as neurological disorders. The
MEDENOX study [30], in fact, focused these clinical
conditions alone or associated with oncological dis-
ease as relevant risk factor for VTE in patients admitted
in hospital.
Inherited thrombophilia. A clear association
between inherited thrombophilia and malignancy for
oncological patients affected by VTE has not been
investigated by large studies. However, several reports
available in the literature showed that subjects carriers
of inherited thrombophilia may not only show an in-
creased incidence of thrombotic complications but also
of relapse of VTE if affected by malignancy, if compared
with subjects with malignancy and without thrombo-
philia. Yet, a preliminary report focused on upper limb
DVT seems to underline a possible association between
thrombophilia and malignancy [31]. On the other hand,
a recent study based on a larger population did not
confirm the association between inherited thrombo-
philia and VTE in patients affected by malignancy [32].
However, this study focused all venous thromboembolic
events and not only upper limb DVT.
So, further studies are needed to understand the
possible link and the effective role of inherited throm-
bophilia in oncological patients.
aCknowledgements
We thank Prof. Giuseppe Castaldo, Dipartimento di
Biochimica e Biotecnologie Mediche e CEINGE-Bio-
tecnologie avanzate; Università di Napoli “Federico II”,
Napoli, Italy, for his helpful suggestions in writing the
review.
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Молекулярные и клинические характеристики,
ассоциированные с венозной троМбоэМболией
у онкологических больных
Связь между опухолевым процессом и гематогенной тромбофилией известна с 1865 г., когда Trousseau впервые дал ее описа-
ние. В последнее время отмечают возрастающий интерес к этой проблеме и связанным с ней молекулярным и клиническим
параметрам, которые учитываются при постоянном наблюдении за больными онкологического профиля. Данный короткий
обзор литературы посвящен характеристике молекулярных факторов, лежащих в основе тромбофилии, возникающей
в процессе развития новообразований, а также другим особенностям клинического течения, индуцирующим тромбофилию
у больных онкологического профиля, таким как хирургическое вмешательство, химиотерапия, сопутствующие осложнения
и наследственная тромбофилия.
Ключевые слова: рак, тромбофилия, гиперсвертываемость, наследственная тромбофилия, химиотерапия.
Copyright © Experimental Oncology, 2006
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