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。      

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。     

肿瘤患者静脉血栓栓塞抗凝出血与复发风险研究进展

肿瘤相关静脉血栓栓塞症(cancer-associated venous thromboembolism, CAVTE)为肿瘤患者在疾病进程中的常见并发症和死亡原因。其静脉血栓栓塞症(venous thromboembolism, VTE)复发和抗凝后严重出血的高风险可能会导致治疗延误和死亡率增加。目前, 国内外指南并未推荐对所有门诊患者直接进行一级预防, 但建议在化疗前评估发生静脉血栓栓塞的个体风险。本文对目前肿瘤患者静脉血栓栓塞抗凝出血与复发研究进展以及现行VTE防治指南和VTE风险评估模型进行综述。      

恶性淋巴瘤血栓形成的研究进展

静脉血栓栓塞（venous thrombolism,VTE）是恶性肿瘤患者第二致死原因,并且癌症患者是血栓栓塞的高发人群,其预防和治疗是非常重要的。肿瘤患者发生VTE的风险较非肿瘤患者至少增加7倍,而血液系统肿瘤并发VTE的概率则较非肿瘤患者增加28倍,严重影响了恶性淋巴瘤患者的预后和生活质量。恶性淋巴瘤患者并发VTE的机制和危险因素尚未明确,VTE的发生与组织因子、微粒以及基因的单核苷酸多态性相关。为了降低VTE发生率,预测可能发生VTE的高危患者是非常重要的,这些患者将会从血栓预防中受益,因此临床上急需一种简单有效的VTE风险评估模型,联合检测外周血中生物标记物可提高VTE诊断率。由于淋巴瘤患者发生出血的风险较高,导致血栓的治疗更加复杂。本文就恶性淋巴瘤患者发生VTE的流行病学、发病机制、预防和治疗的最新研究做一综述。      

恶性肿瘤相关静脉血栓栓塞症的研究进展

静脉血栓栓塞症（VTE）是恶性肿瘤的常见并发症之一,发生率为4％～20％,也是导致肿瘤患者死亡的主要原因之一。住院和接受积极治疗的肿瘤患者是VTE的高发人群。VTE将增加肿瘤患者的致残率和致死率,影响抗肿瘤的疗效,加重医疗资源及患者的负担。国际上采用风险预测模型可以有效评估VTE的风险因素,以便有针对性地实施预防性抗凝治疗策略。近年来越来越多的临床研究显示,在肿瘤患者中积极防治VET有较多的益处。     

肿瘤与静脉血栓栓塞症

 肿瘤患者有较高的静脉血栓发生率。研究发现,静脉血栓栓塞症（VTE）可增加肿瘤患者的死亡风险。VTE的发生机制与组织因子（TF）及癌促凝物质（CP）等因素密切相关。患者相关性因素、肿瘤相关性因素及治疗相关性因素均可导致患者VTE发生率增加。应重视对患者危险因素进行评估,对高危患者及早进行预防性抗凝治疗,在诊断VTE后应立即进行急性期治疗及慢性期维持治疗。     

Caprini和Rogers血栓风险评估模型在胸外科肺癌患者围手术期应用的验证研究

目的：对Caprini和Rogers血栓风险评估模型在胸外科肺癌患者围术期筛查静脉血栓栓塞症（Venous Thromboembolism, VTE）高风险的适用性进行分析,以验证其有效性。方法：根据入排标准纳入2015年3月至2017年3月在四川省肿瘤医院胸外科接受手术治疗的肺癌患者,术后未预防性抗凝处理。所有患者围术期行双下肢血管彩超检查,怀疑肺血管栓塞者行胸CT检查,前瞻性收集临床和实验室相关指标。以Caprini和Rogers血栓风险评估量表对所有患者进行血栓风险评分。分别分析Caprini和Rogers评分不同层级组之间术后VTE发生率、危险因素、实验室指标的差异。结果：152例肺癌患者入选本研究,术后深静脉血栓（Deep Vein Thrombosis, DVT）发生率25%（38/152）,无肺栓塞发生。全组患者Caprini评分为8～15分,均至少为VTE高风险层级,其中高危组（5-8分）66例,极高危组（＞9分）86例;两组DVT发生率为26.6% vs.21.3%（P=0.46）,差异无统计学意义。全组Rogers评分9-18分,其中低危组（7-10分）67例,中高危组（＞10分）85例;低危组与中高危组DVT发生率为25.4% vs.22.1%（p=0.64）,差异无统计学意义。Caprini评分高危组与极高危组之间和Rogers评分低危组与中高危组之间在DVT危险因素吸烟指数、血型构成、合并COPD病史、组织学类型、VATS、手术时间、术后卧床时间、病理学分期的差异均无统计学意义（p＞0.05）;在围术期各时点的凝血指标及NLR（中性-淋巴细胞比值）的差异亦无统计学意义。结论：Caprini血栓风险评估模型评价胸外科肺癌手术患者易评为VTE高风险人群,对预防VTE具有积极的指导意义,但Caprini和Rogers血栓风险评估模型对胸外科肺癌患者围术期VTE风险层级评估的有效性尚不确切,应探索建立符合我国肺癌人群特质的胸外科血栓风险评估量表体系。     

恶性肿瘤与静脉血栓栓塞的研究进展

静脉血栓栓塞（VTE）是恶性肿瘤患者常见并发症,是仅次于肿瘤本身引起患者死亡的第二位原因。血栓有时可作为隐匿性癌的初始表现。血栓形成参与了肿瘤的进展、血管生成和转移等机制。恶性肿瘤患者合并血栓栓塞不仅增加治疗难度,而且降低患者的生存质量并缩短生存时间。抗凝治疗不仅能有效的治疗血栓,而且具有一定的抗肿瘤作用。低分子肝素（LMWH）作为预防和治疗静脉血栓栓塞有效的和安全的首选药物,其优点包括延长生存时间和改善生活质量,减少静脉血栓栓塞的发生率。推荐在院的及接受手术治疗的肿瘤患者预防性使用LMWH。LMWH应作为已确诊的和存在再发可能的VTE的肿瘤患者的一线治疗。     

恶性肿瘤与静脉血栓栓塞的研究进展

静脉血栓栓塞(VTE)是恶性肿瘤患者常见并发症,是仅次于肿瘤本身引起患者死亡的第二位原因。血栓有时可作为隐匿性癌的初始表现。血栓形成参与了肿瘤的进展、血管生成和转移等机制。恶性肿瘤患者合并血栓栓塞不仅增加治疗难度,而且降低患者的生存质量并缩短生存时间。抗凝治疗不仅能有效的治疗血栓,而且具有一定的抗肿瘤作用。低分子肝素(LMWH)作为预防和治疗静脉血栓栓塞有效的和安全的首选药物,其优点包括延长生存时间和改善生活质量,减少静脉血栓栓塞的发生率。推荐在院的及接受手术治疗的肿瘤患者预防性使用LMWH。LMWH应作为已确诊的和存在再发可能的VTE的肿瘤患者的一线治疗。     

恶性肿瘤抗凝治疗后肝素诱导血小板减少症的诊断与治疗进展

恶性肿瘤患者多伴有凝血机制的异常,如血小板增多、血小板聚集功能亢进等,从而导致血栓发生,是恶性肿瘤最常见的并发症之一。根据发生血栓的流行病学调查显示,恶性肿瘤患者发生静脉血栓栓塞症（VTE）的风险约为非恶性肿瘤患者的4～7倍。目前有关发生恶性肿瘤相关血栓的危险因素包括患者、恶性肿瘤及治疗相关因素,可根据恶性肿瘤相关血栓的生物学标志物及其危险模型进行评估,并对其进行预防及治疗。恶性肿瘤患者发生VTE一般采用肝素或低分子肝素治疗,但经肝素抗凝治疗后又常常发生血小板减少,导致患者的皮肤黏膜广泛出血及器官出血。因此,本文就恶性肿瘤相关血栓发生的原因、抗凝治疗后肝素诱导血小板减少症的临床和实验室诊断及其临床治疗进展作一综述,供血液肿瘤科的临床医师讨论和参考。     

Low molecular weight heparins as extended prophylaxis against recurrent thrombosis in cancer patients

Cancer has been shown to be an independent risk factor for the development of venous thromboembolism (VTE; deep vein thrombosis and pulmonary embolism). Thromboprophylaxis reduces the incidence of VTE in patients with cancer; however, active cancer places patients at high risk for recurrent VTE, necessitating extended prophylactic regimens. Extended prophylaxis in patients with cancer can be problematic because of increased risk for bleeding. Oral anticoagulants, such as warfarin, have been the standard of care for extended prophylaxis, but maintaining a clinically effective level of anticoagulation can be difficult because of a wide range of drug interactions, a narrow therapeutic window, and an increased risk of bleeding complications, particularly in patients with cancer. Recent evidence indicates that long-term prophylaxis with low-molecular-weight heparins (LMWHs) is an effective and safe alternative to oral anticoagulation in patients with VTE and cancer, reducing the risk for recurrent VTE by up to 52%. LMWHs can also be seen as cost-effective for long-term prophylaxis, because higher drug acquisition costs are offset by the potential for reduced hospital stays, reduced need for coagulation monitoring, and fewer bleeding complications. Some studies suggest that LMWHs may also have direct antitumor effects and improve survival rates, most notably in patients with non-metastatic disease. Further clinical research is needed to evaluate the potential survival benefits of LMWH therapy in patients with cancer.     

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.     

肺癌围术期患者静脉血栓栓塞症的预防与护理现状调查分析

背景与目的 了解我国医院肺癌围术期患者静脉血栓栓塞症(venous thromboembolism, VTE)的预防与护理现状.方法 采用自行设计的调查问卷,在第一届胸科加速康复外科(enhanced recovery after surgery, ERAS)华西论坛上,对全国108名胸外科护士长进行调查.结果 ①评估工具与预防规范:97.22%的医院已采用不同评估工具对肺癌围术期患者进行VTE风险分级,其中67.59%的医院已形成VTE预防护理规范.②筛查、预防与随访:56.48%的医院对肺癌患者进行了VTE术前筛查,90.74%的医院对住院患者进行了VTE预防,52.78%的医院对出院患者继续进行了VTE预防,仅有17.59%医院对出院患者VTE的发生情况进行了随访.③不同类型医院肺癌围术期患者VTE预防现状相比,差异无统计学意义(P>0.05),但在VTE风险评估、住院患者VTE预防方面专科医院所有患者已全面实现(100.00%).结论 肺癌围术期VTE预防工作已受到广泛重视,但尚缺乏有效的VTE风险评估工具和标准化的VTE预防护理指南.     

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.     

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.     

Long-term therapy of venous thromboembolism in cancer patients

Venous thromboembolism (VTE) is a common complication in cancer patients that results in significant morbidity and mortality. Long-term treatment options for cancer patients who experience VTE include vitamin K antagonists (VKAs), low molecular weight heparins (LMWHs), and inferior vena caval (IVC) filters. Cancer patients have a two- to fourfold higher risk for experiencing recurrent VTE and major bleeding during chronic VKA therapy than patients without malignancies. Recent randomized clinical trials have shown that LMWHs rather than oral VKAs are preferred for initial chronic treatment of VTE in patients with advanced cancer. One factor potentially limiting the broader use of LMWH for chronic therapy in the United States is its higher acquisition cost. Efficacy, cost, drug availability, patient comorbidities, and concomitant medications all need to be considered when selecting chronic VTE therapy. Cancer patients with VTE should be treated for as long as their disease is active to minimize the incidence of recurrence. Use of IVC filters should generally be reserved for patients at high risk for recurrent VTE who have contraindications to anticoagulation. Several new anticoagulants are being investigated that promise greater therapeutic choices and potentially better outcomes for cancer patients with VTE.