Pulmonary embolism at autopsy in cancer patients

Gimbel, Inge A.; Mulder, Frits I.; Bosch, Floris T. M.; Freund, Jan Erik; Guman, Noori A.M.; Es, Nick van; Kamphuisen, Pieter Willem; Büller, Harry R.

doi:10.1111/jth.15250

Cited by 35 publications

(27 citation statements)

References 25 publications

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“…Previous studies have reported a 5-10% prevalence of pulmonary embolism in autopsied cancer patients. 57,58 Such deaths due to venous thromboembolism would have been misclassified as competing risk mortality instead of counting as a venous thromboembolic event, potentially leading to underestimation of incidence of venous thromboembolism.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Validation of the Khorana score for predicting venous thromboembolism in 40 218 patients with cancer initiating chemotherapy

et al. 2022

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The Khorana score is recommended for guiding primary venous thromboembolism prophylaxis in cancer patients, but its clinical utility overall and across cancer types remains debatable. Also, some previous validation studies have ignored competing risk of death, hereby potentially overestimating venous thromboembolism risk. We identified ambulatory cancer patients initiating chemotherapy without other indications for anticoagulation using Danish health registries and estimated six-month cumulative incidence of venous thromboembolism stratified by Khorana levels. Analyses were conducted with and without considering death as competing risk using the Kaplan-Meier method versus the cumulative incidence function. Analyses were performed overall and stratified by cancer types. Of 40,218 patients, 35.4% were categorized by Khorana as low risk (score 0), 53.6% as intermediate risk (score 1-2) and 10.9% as high risk (score ≥3). Considering competing risk of death, the corresponding six-month risks of venous thromboembolism were 1.5% (95% CI 1.3-1-7), 2.8% (95% CI 2.6-3.1), and 4.1% (95% CI 3.5-4.7), respectively. Among patients recommended anticoagulation by guidelines (Khorana score ≥2), six-month risk was 3.6% (95% CI 3.3-3.9). Kaplan-Meier analysis overestimated incidence up to 23% compared with competing risk analyses. Using the guideline-recommended threshold of ≥2, the Khorana score did not risk stratify patients with hepatobiliary or pancreatic cancer, lung cancer, and gynecologic cancer. In conclusion, the Khorana score was able to stratify ambulatory cancer patients according to risk of venous thromboembolism, but not for all cancer types. Absolute risks varied by methodology but were lower than in key randomized trials. Thus, although certain limitations with outcome identification using administrative registries apply, the absolute benefit of implementing routine primary thromboprophylaxis in an unselected cancer population may be smaller than seen in randomized trials.

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Section: Strengths and Limitationsmentioning

confidence: 99%

Validation of the Khorana score for predicting venous thromboembolism in 40 218 patients with cancer initiating chemotherapy

et al. 2022

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“…Reasons for these findings were unclear but could be postulated. Incidental VTE may not be thrombotic in nature as a recent large Dutch study showed a noticeable portion of PE (14.1%) observed at autopsy in cancer patients were tumor embolism, along with other types (septic, fat tissue, bone marrow) 43 . In addition, incidental VTE might already be subacute or chronic at the time of diagnosis.…”

Section: Discussionmentioning

confidence: 99%

“…Incidental VTE may not be thrombotic in nature as a recent large Dutch study showed a noticeable portion of PE (14.1%) observed at autopsy in cancer patients were tumor embolism, along with other types (septic, fat tissue, bone marrow). 43 11,19 Therefore, although incidental VTE may be associated with a lower rate of recurrent events, its prognostic role on overall mortality may be related to advanced or aggressive underlying malignancy 23 or poor performance status. 31 This study has limitations that are important to consider.…”

Section: Discussionmentioning

confidence: 99%

Outcomes among patients with cancer and incidental or symptomatic venous thromboembolism: A systematic review and meta‐analysis

Caiano

Carrier

Marshall

et al. 2021

Journal of Thrombosis and Haemostasis

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Summary Background Patients with cancer have an increased risk of venous thromboembolism (VTE) and it is commonly detected incidentally. The outcomes and optimal management for patients with cancer and incidental VTE remain debated. Objectives We conducted a systematic review and meta‐analysis to evaluate the outcomes in patients with cancer and incidentally detected VTE compared to those with symptomatic events. Patients/Methods We searched the electronic databases and included randomized controlled trials (RCTs) and observational studies reporting recurrent VTE, major bleeding events, and mortality in patients with cancer and incidental VTE compared to symptomatic VTE. Results We included 23 studies for the systematic review: 3 RCTs and 20 observational studies. The meta‐analysis of the 3 RCTs showed a significantly lower rate of VTE recurrence at 6 months in patients with incidental VTE compared to those with symptomatic VTE (relative risk [RR] 0.62, 95% confidence interval [CI] 0.44–0.87). The risk of major bleeding events at 6 months was numerically higher with incidental VTE compared to symptomatic VTE (RR 1.47, 95% CI 0.99–2.20). There was no difference in overall mortality. Conclusions Among patients with cancer, incidental VTE was associated with a lower rate of VTE recurrence compared to symptomatic VTE, with a trend in increased major bleeding events. The risk‐benefit ratio of anticoagulation may differ between incidental and symptomatic events and should be considered in patient management.

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“…In a recent autopsy study including almost 10,000 cancer patients, Gimbel et al reported a non-neglectable and stable over time proportion of cancer patients with PE using autopsies from 2008 (incidence = 11.7%, 95% CI (10.0–13.7)) to 2019 (incidence = 15.1%, 95% CI (11.9–18.7)) [ 33 ]. These data highlight that the diagnosis of PE in cancer patients remains extremely challenging and that the rate of fatal PE is severely underestimated [ 33 , 34 , 35 , 36 , 37 ]. The real rate of PE ranges from 10 to 35% and most likely depends on the type of cancer, with a higher risk in pancreatic, gynecological, lung, and biliary cancers [ 33 , 35 ].…”

Section: Epidemiologymentioning

confidence: 99%

Pulmonary Embolism in the Cancer Associated Thrombosis Landscape

Poénou

Dumitru

Lafaie

et al. 2022

JCM

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In cancer patients, pulmonary embolism (PE) is the second leading cause of death after the cancer itself, most likely because of difficulties in diagnosing the disease due to its nonclassical presentation. The risk of PE recurrence and possibly the case-fatality rate depends on whether the patient presents a symptomatic PE, an unsuspected PE, a subsegmental PE, or a catheter-related PE. Choosing the best therapeutic option is challenging and should consider the risk of both the recurrence of thrombosis and the occurrence of bleeding. The purpose of this review is to provide an overview of the clinical characteristics and the treatment of cancer-associated PE, which could benefit clinicians to better manage the deadliest form of thrombosis associated with cancer. After a brief presentation of the epidemiological data, we will present the current attitude towards the diagnosis and the management of cancer patients with PE. Finally, we will discuss the perspectives of how the medical community can improve the management of this severe medical condition.

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Pulmonary embolism at autopsy in cancer patients

Abstract: This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Cited by 35 publications

References 25 publications

Validation of the Khorana score for predicting venous thromboembolism in 40 218 patients with cancer initiating chemotherapy

Validation of the Khorana score for predicting venous thromboembolism in 40 218 patients with cancer initiating chemotherapy

Outcomes among patients with cancer and incidental or symptomatic venous thromboembolism: A systematic review and meta‐analysis

Pulmonary Embolism in the Cancer Associated Thrombosis Landscape

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