肿瘤相关静脉血栓栓塞症的预防与治疗中国专家指南（2015版）

《中国肿瘤临床》2015年第20期刊登由中国临床肿瘤学会（CSCO）肿瘤与血栓专家共识委员会的多位权威专家撰写的《肿瘤相关静脉血栓栓塞症的预防与治疗中国专家指南（2015年版）》，该指南对肿瘤患者静脉血栓栓塞症（venous thromboembolism，VTE）的发生率、危险因素、预防方法与治疗原则进行了系统总结，供肿瘤临床医师参考，以期降低肿瘤患者VTE率，提高生存质量。欢迎登陆本刊网站浏览与下载该文。     

晚期恶性肿瘤患者合并静脉血栓栓塞症18例临床分析

静脉血栓栓塞症(venous thromboembolism,VTE)是指堵塞静脉血管的血凝块(血栓)形成,血栓形成在不同部位、不同阶段会出现不同表现,包括深静脉血栓(deep venous thrombosis,DVT)和肺血栓栓塞症(pulmonary thromboembolism,PTE),是目前医学界公认的具潜在致命性的常见疾病之一,是恶性肿瘤患者,尤其是长期卧床患者的主要合并症.2003至2007年我科共收治恶性肿瘤并发静脉血栓栓塞患者18例,现报告如下.     

82例血液恶性肿瘤合并静脉血栓栓塞症患者的临床特点分析

目的:探讨血液系统肿瘤患者合并静脉血栓栓塞症(venous thromboembolism,VTE)的临床特点.方法:回顾性分析2012年1月至2020年12月宁夏医科大学总医院收治的82例血液肿瘤合并VTE患者的住院资料并作为病例组,以同期100例未合并VTE的血液肿瘤患者为对照组.结果:血液肿瘤并发VTE以急性白血...     

肿瘤患者静脉血栓栓塞症的一级预防及研究进展

肿瘤相关静脉血栓栓塞症(cancer-associated venous thromboembolism,CAVTE)是肿瘤患者常见的并发症和死亡原因。因此,如何预防CAVTE的发生受到越来越多的关注。预防性抗凝治疗可以降低肿瘤患者的血栓发生风险,因此需要将患者的获益和不良反应进行充分评估,排除抗凝治疗禁忌后,对血栓高危患者进行预防性的抗凝治疗。     

恶性肿瘤相关静脉血栓形成因素及预防研究

静脉血栓栓塞(venous thromboembolism,VTE)是肿瘤发展及抗肿瘤治疗过程中的常见并发症,主要包括深静脉血栓形成(deep venous thrombosis,DVT)和肺栓塞(pulmonary embolism,PE).由于患者肿瘤类型及其它危险因素的差异,其发生率为1%～25%.目前的观察数据显示肿瘤相关血栓形成呈上升趋势.     

肿瘤患者VTE风险评估模型的研究进展

静脉血栓栓塞（venous thromboembolism,VTE）已经成为肿瘤患者最常见的并发症,且成为除肿瘤患者外第二大死因。肿瘤本身是一种存在血栓和出血双风险并存的状态,对患者能够进行有效风险评估筛查的模型显得尤为关键。只有能在对肿瘤患者进行精准的风险分层,低风险患者能够不进行血栓预防或仅进行机械预防降低治疗成本和出血风险,高风险患者预防血栓中获益。本文对目前肿瘤并发相关VTE的情况、当前VTE风险评估模型的对比、风险模型的建立及未来发展方向进行探讨,旨在提高对相关VTE风险评估模型的的认识,并对风险模型的建立和发展提出理论支持。      

回生口服液用于非小细胞肺癌围手术期抗凝治疗专家共识(2016版)

原发性肺癌是我国发病率和死亡率增长最快,对人群健康和生命威胁最大的恶性肿瘤,也是导致我国人群癌症相关死亡的首要原因[1,2].非小细胞肺癌占全部肺癌患者的85％左右.迄今为止,手术治疗仍是早期非小细胞肺癌的最佳治疗方法[1].静脉血栓栓塞症(venous thromboembolism,VTE)是肺癌最常见的并发症并影响预后[2],已成为导致肿瘤患者死亡的第2位原因[3].美国临床肿瘤学会(American Society of Clinical Oncology,ASCO)在2010年颁布的“恶性肿瘤患者静脉血栓防治指南”表明,癌症患者,特别是接受大手术或全身性治疗的患者,静脉血栓栓塞的风险显著增加.     

肺癌静脉血栓栓塞的危险因素及生物标志物的研究进展

癌症是引起静脉血栓栓塞(venous thromboembolism,VTE)的重要危险因素,而VTE是引起肿瘤患者死亡的重要原因。肺癌患者VTE的发生率在不同的研究中结果有所差别,发生率从7%~13%不等,其中还包括大量可疑肺栓塞病例。肺癌患者VTE发生的危险因素可以分为三类:患者自身特征、肿瘤相关因素以及治疗相关的因素。此外,许多生物标志物也被发现可以作为VTE发生的危险因素(例如D-二聚体)。了解肺癌VTE发生的危险因素对于预防血栓并发症的发生、改善肺癌患者的治疗方面具有重要的意义。本文就VTE危险因素及生物标志物进行综述。     

肿瘤患者静脉血栓栓塞症的风险评估模型及其应用

静脉血栓栓塞症（VTE）是肿瘤患者常见的并发症和死亡原因。多项研究显示,有效的VTE风险评估模型和恰当的预防性抗凝治疗可以降低肿瘤患者的血栓发生风险。但哪些肿瘤患者需要进行预防性抗凝治疗,需要有效的VTE风险评估模型,对肿瘤患者进行VTE风险分层。对血栓高危人群,在排除抗凝禁忌证后进行预防性抗凝。但肿瘤疾病存在复杂性,不同的病理类型和分期,VTE风险和特点不同,而目前专门针对肿瘤患者的VTE风险评估模型仍然有限,本文将对肿瘤患者的VTE风险评估模型的现状及其应用进行综述。     

99例晚期恶性肿瘤患者静脉血栓栓塞症的诊治情况分析

目的:了解晚期恶性肿瘤患者合并静脉血栓栓塞症（venous thromboembolism,VTE)的诊治及预防情况,加强肿瘤相关性VTE的认知,提高患者生活质量及改善预后。方法:收集2012年1月至2016年10月住院确诊为VTE的肿瘤患者（VTE组）的病历资料,与同时期入院的非VTE的肿瘤患者对照（对照组）,对两组资料进行Logistic回归分析,寻找可能的VTE高危因素。结果:VTE组及对照组各99例患者。VTE组中,年龄>60岁64例,ZPS评分>2分57例,IV期65例;以彩超确诊者84例,以CT诊断者15例;发生在下肢深静脉者71例。VTE组:49例应用低分子肝素抗凝,出院后应用华法林后续治疗10例,大多数VTE组患者未应用预防性抗凝。在多因素Logistic回归分析中,血红蛋白下降、凝血酶时间延长以及中心静脉置管的应用在统计学上存在显著的差异。结论:恶性肿瘤合并VTE多发生在60岁以上、IV期和活动不良的患者,其后续抗凝治疗不足,临床上缺乏主动预防的措施及意识。     

肿瘤相关静脉血栓栓塞症中新型口服抗凝药应用进展

目的回顾NOACs在治疗CAVTE中的特点、疗效、不良反应及相关进展,并讨论其在CAVTE中面临的挑战及前景。方法应用PubMed、CNKI、万方数据库和维普中文科技期刊数据库检索系统,以"new oral anticoagulants、cancer-associated venous thromboembolism、low molecular weight heparin"及"新型口服抗凝药、肿瘤相关静脉血栓、低分子肝素"为关键词,检索2009-10-2019-10的相关文献。纳入标准:(1)NOACs;(2)CAVTE;(3)NOACs治疗CAVTE的病例对照研究。根据纳入标准分析文献44篇,其中中文4篇,英文40篇。结果NOACs在治疗肿瘤相关静脉血栓中的疗效不低于传统治疗药物,VTE复发风险低于低分子肝素,在非消化道肿瘤中其主要出血不良反应可耐受,患者依从性较好。但肿瘤患者存在特殊性,CAVTE应用NOACs的抗凝与出血风险评估、抗凝疗程周期、抗凝剂量、不良反应监测和相互作用等方面都面临挑战,均需充分权衡利弊,进行个体化抗凝管理。结论NOACs在CAVTE中的治疗越来越受到关注,应用日益广泛。但NOACs也面临一些挑战,CAVTE应用NOACs的获益需要更多的研究数据支持,而血栓与出血风险的权衡需要大量基于临床经验的个体化治疗。     

Thromboprophylaxis with low‐molecular‐weight heparin in medical patients with cancer

Venous thromboembolism (VTE) is a frequent complication of cancer and cancer treatment and is associated with multiple clinical consequences, including recurrent VTE, bleeding, and an increase in the risk of death. Although the risks associated with VTE have been well recognized in surgical cancer patients, there is also considerable and increasing risk in medical cancer patients. VTE risk factors in medical cancer patients include the type and stage of cancer, major comorbid illnesses, current hospitalization, active chemotherapy, hormone therapy, and antiangiogenic agents. Low‐molecular‐weight heparins (LMWHs) are recommended commonly for the prevention of VTE in hospitalized cancer patients and in higher risk ambulatory cancer patients because of their favorable risk‐to‐benefit profile. These agents have demonstrated effectiveness in both the primary and secondary prevention of VTE in medical cancer patients. Extended‐duration anticoagulant therapy is often recommended to reduce the risk of VTE recurrence in patients with cancer. LMWHs are often used for long‐term prophylaxis because of a reduced need for coagulation monitoring, few major bleeding episodes, and once‐daily dosing. Despite clinical and practical benefits, a substantial proportion of medical cancer patients do not receive VTE prophylaxis. To improve the appropriate prevention and treatment of VTE in cancer patients, guidelines have been published recently by the American Society of Clinical Oncology and the National Comprehensive Cancer Network. Widespread dissemination and application of these guidelines are encouraged to improve the appropriate use of these agents and to improve clinical outcomes in medical cancer patients at risk for VTE and its complications. Cancer 2009. © 2009 American Cancer Society.     

Risk assessment models for cancer-associated venous thromboembolism

Venous thromboembolism (VTE) is common in cancer patients, and is associated with significant morbidity and mortality. Several factors, including procoagulant agents secreted by tumor cells, immobilization, surgery, indwelling catheters, and systemic treatment (including chemotherapy), contribute to an increased risk of VTE in cancer patients. There is growing interest in instituting primary prophylaxis in high-risk patients to prevent incident (first-time) VTE events. The identification of patients at sufficiently high risk of VTE to warrant primary thromboprophylaxis is essential, as anticoagulation may be associated with a higher risk of bleeding. Current guidelines recommend the use of pharmacological thromboprophylaxis in postoperative and hospitalized cancer patients, as well as ambulatory cancer patients receiving thalidomide or lenalidomide in combination with high-dose dexamethasone or chemotherapy, in the absence of contraindications to anticoagulation. However, the majority of cancer patients are ambulatory, and currently primary thromboprophylaxis is not recommended for these patients, even those considered at very high risk. In this concise review, the authors discuss risk stratification models that have been specifically developed to identify cancer patients at high risk for VTE, and thus might be useful in future studies designed to determine the potential benefit of primary thromboprophylaxis.     

The NCCN Clinical Practice Guidelines on Venous Thromboembolic Disease: strategies for improving VTE prophylaxis in hospitalized cancer patients

The risk for venous thromboembolism (VTE) is high in hospitalized cancer patients, and is associated with an elevated risk for recurrent thrombosis, bleeding complications, and use of health care resources. Thromboembolism is the second leading cause of death in hospitalized cancer patients. Thromboprophylaxis with unfractionated heparin or low-molecular-weight heparins has been clinically proven to reduce the risk for VTE and improve outcomes. However, VTE prophylaxis continues to be underprescribed in cancer patients. Recognizing the clinical burden of VTE in cancer patients, the National Comprehensive Cancer Network (NCCN) recently released guidelines for VTE prevention and management. These NCCN guidelines recommend evidence-based prophylactic anticoagulant therapy for all patients admitted to hospital with a diagnosis of cancer who do not have contraindications to anticoagulant use. However, there continue to be barriers to the implementation of clinical practice guidelines and appropriate use of VTE prophylaxis. Multifaceted active educational and electronic interventions are necessary to raise awareness and reduce the burden of cancer-associated thrombosis and its attendant consequences.     

Cancer and thrombosis: implications of published guidelines for clinical practice

Cancer is a frequent finding in patients with thrombosis, and thrombosis is much more prevalent in patients with cancer, with important clinical consequences. Thrombosis is the second most common cause of death in cancer patients. Venous thromboembolism (VTE) in cancer is also associated with a high rate of recurrence, bleeding, a requirement for long-term anticoagulation, and worsened quality of life. Risk factors for cancer-associated VTE include particular cancer types, chemotherapy (with or without antiangiogenic agents), the use of erythropoietin-stimulating agents, the presence of central venous catheters, and surgery. Novel risk factors include platelet and leukocyte counts and tissue factor. A risk model for identifying cancer patients at highest risk for VTE has recently been developed. Anticoagulant therapy is safe and efficacious for prophylaxis and treatment of VTE in patients with cancer. Available anticoagulants include warfarin, heparin, and low-molecular weight heparins (LMWHs). LMWHs represent the preferred therapeutic option for VTE prophylaxis and treatment. Their use may be associated with improved survival in cancer, although this issue requires further study. Despite the significant burden imposed by VTE and the availability of effective anticoagulant therapies, many oncology patients do not receive appropriate VTE prophylaxis as recommended by practice guidelines. Improved adherence to guidelines could substantially reduce morbidity, decrease resource use, enhance quality of life, and improve survival in these patients.     

Treatment of cancer-associated venous thromboembolism in the age of direct oral anticoagulants

Anticoagulation for cancer-associated venous thromboembolism (VTE) can be challenging due to complications—including bleeding and potential drug–drug interactions with chemotherapy—associated with vitamin K antagonists and inconvenience of low-molecular-weight heparin (LMWH). Direct oral anticoagulants (DOACs) could partially overcome these issues, but until recently there were no large clinical trials assessing their efficacy and safety in cancer patients. This review summarizes clinical treatment guidelines, prior clinical and real-world evidence for anticoagulant choice, recent clinical trials assessing DOACs for cancer-associated VTE (i.e. Hokusai-VTE Cancer, SELECT-D, CARAVAGGIO, and ADAM VTE), and special considerations for DOAC use. Based on established data, clinical guidelines recommend patients with cancer-associated VTE receive LMWH treatment of at least 3–6 months. Nevertheless, LMWH is underused and associated with poor compliance and persistence in these patients relative to oral anticoagulants. Clinical data supporting DOAC use in cancer patients are becoming available. In Hokusai-VTE Cancer, edoxaban was noninferior to dalteparin for the composite of recurrent VTE and major bleeding (12.8% versus 13.5%), with numerically lower recurrent VTE (7.9% versus 11.3%) and significantly higher major bleeding (6.9% versus 4.0%); only patients with gastrointestinal cancer had significantly higher risk of bleeding with edoxaban. In SELECT-D, rivaroxaban had numerically lower VTE recurrence (4% versus 11%), comparable major bleeding (6% versus 4%), and numerically higher clinically relevant nonmajor bleeding (13% versus 4%) versus dalteparin. Most bleeding events were gastrointestinal or urologic; patients with esophageal/gastroesophageal cancer had higher rates of major bleeding with rivaroxaban (36% versus 11%). For comparison of apixaban versus dalteparin, CARAVAGGIO is ongoing, and preliminary results from ADAM VTE are favorable. This review concludes that DOACs appear to be reasonable alternatives to LMWH for treatment of cancer-associated VTE. In patients with gastrointestinal cancer, DOAC use should be considered on a case-by-case basis with consideration of the relative risks and benefits.     

Thrombosis and cancer

Venous thromboembolism (VTE) is a potentially life-threatening condition that can be associated with significant morbidity. Thrombosis and cancer are linked by numerous pathophysiological mechanisms; the frequency of VTE and the recurrence rate are increased in the cancer population in comparison with other patient groups. VTE is the second most common cause of death in patients with cancer, but can also be the initial presenting complaint in patients with an occult malignancy. Risk factors for cancer-related VTE include tumour type, surgery, chemotherapy and the use of central venous catheters; predictors of VTE for individuals are only now beginning to emerge. Patients with cancer who develop symptomatic VTE during chemotherapy are at a greater risk of early mortality than those without VTE. The apparent impact of VTE on early mortality in patients with cancer raises the question of whether anticoagulation might improve long-term survival in this population, by direct tumour biology-modifying mechanisms. There are widely published guidelines that highlight the benefits of effective VTE strategies in patients with cancer. In partnership with the patient and their carers, the clinical team can improve patient outcomes with optimal risk assessment and concordance with national and international guidelines in the prophylaxis and treatment of VTE.     

Prevention of venous thromboembolism in cancer patients: current approaches and opportunities for improvement

Venous thromboembolism (VTE), a common complication in patients with cancer, is associated with increased risk of morbidity, mortality, and recurrent VTE. Risk factors for VTE in cancer patients include the type and stage of cancer, comorbidities, age, major surgery, and active chemotherapy. Evidence-based guidelines for thromboprophylaxis in cancer patients have been published: the National Comprehensive Cancer Network and American Society for Clinical Oncology guidelines recommend thromboprophylaxis for hospitalized cancer patients, while the American College of Chest Physician guidelines recommend thromboprophylaxis for surgical patients with cancer and bedridden cancer patients with an acute medical illness. Guidelines do not generally recommend routine thromboprophylaxis in ambulatory patients during chemotherapy, but there is evidence that some of these patients are at risk of VTE; some may be at higher risk while on active chemotherapy. Approaches are needed to identify those patients most likely to benefit from thromboprophylaxis, and, to this end, a risk assessment model has been developed and validated. Despite the benefits, many at-risk patients do not receive any thromboprophylaxis, or receive prophylaxis that is not compliant with guideline recommendations. Quality improvement initiatives have been developed by the Centers for Medicare and Medicaid Services, National Quality Forum, and Joint Commission to encourage closure of the gap between guideline recommendations and clinical practice for prevention, diagnosis, and treatment of VTE in hospitalized patients. Health-care institutions and providers need to take seriously the burden of VTE, improve prophylaxis rates in patients with cancer, and address the need for prophylaxis across the patient continuum.