Viscoelastic testing in oncology patients (including for the diagnosis of fibrinolysis): Review of existing evidence, technology comparison, and clinical utility

Abstract

The quantification of the coagulopathic state associated with oncologic and hematologic diseases is imperfectly assessed by common coagulation tests such as prothrombin time, activated partial thromboplastin time, fibrinogen levels, and platelet count. These tests provide a static representation of a component of hemostatic integrity, presenting an incomplete picture of coagulation in these patients. Viscoelastic tests (VETs), such as rotational thromboelastometry (ROTEM) and thromboelastography (TEG), as whole blood analyses, provide data related to the cumulative effects of blood components and all stages of the coagulation and fibrinolytic processes. The utility of VETs has been demonstrated since the late 1960s in guiding blood component therapy for patients undergoing liver transplantation. Since then, the scope of viscoelastic testing has expanded to become routinely used for cardiac surgery, obstetrics, and trauma. In the past decade, VETs' expanded usage has been most significant in trauma resuscitation. However, use of VETs for patients with malignancy‐associated coagulopathy (MAC) and hematologic malignancies is increasing. For the purposes of this narrative review, we discuss the similarities between trauma‐induced coagulopathy (TIC) and MAC. These similarities center on the thrombomodulin‐thrombin complex as it switches between the thrombin‐activatable fibrinolysis inhibitor coagulation pathway and activating the protein C anticoagulation pathway. This produces a spectrum of coagulopathy and fibrinolytic alterations ranging from shutdown to hyperfibrinolysis that are common to TIC, MAC, and hematologic malignancies. There is expanding literature regarding the utility of TEG and ROTEM to describe the hemostatic integrity of patients with oncologic and hematologic conditions, which we review here.

The Hypercoagulable Profile of Patients with Bone Tumors: A Pilot Observational Study Using Rotational Thromboelastometry

“…The risk of a clinically significant VTE is four-to-seven times higher in oncologic patients compared to the general population [ 20 ]. Many causes such as malignancy-induced platelet activation have been implicated in cancer-associated thrombosis while various factors related to surgery, such as endothelial damage and massive release of tissue factor, also add to the overall increased thrombotic risk [ 21 , 22 ]. Further understanding the hemostatic derangements that result in the prothrombotic state of surgical oncologic patients may allow for the development of targeted thrombophylactic measures focused on specific aspects of the hemostatic mechanism.…”

The quantra hemostasis analyzer compared to thromboelastography (TEG) in the surgical oncologic population: A prospective observational trial

“…LY30 is helpful in diagnosing intraoperative coagulopathy due to disseminated intravascular coagulation (DIC) and can guide the administration of antifibrinolytics. It can also be used to help predict patients that are risk for developing venous thromboembolism, which is especially critical in oncologic populations that are prone to thrombotic events 15 …”

“…This information has led to the inclusion of viscoelastic testing in several transfusion guidelines 12–14 . Examples of VEA tests include thromboelastography (TEG®: Haemonetics Corporation), rotational thromboelastometry (ROTEM®: Instrumentation Laboratory), and the Quantra® System (Hemosonics, Quantra) 15 …”

“…With ROTEM, the warmed cup with citrate blood stays stationary as the pin revolves within the fixed cup. Similar to TEG, the resultant torque of the clot on the pin is then transduced as a shovel‐shaped curve 15 …”

Correlation of Hemostatic Parameters with Poly (ADP-ribose) Polymerase-1 (PARP-1) Polymorphisms, Mutations, Laboratory, and Clinical Characteristics in 114 Patients with Philadelphia-Negative Myeloproliferative Neoplasms

“…Global assays, such as thromboelastometry, may be more useful than conventional hemostatic laboratory tests in depicting the hypercoagulable state in oncologic and hematologic diseases [34]. Thorson et al demonstrated that intra-abdominal malignancies are associated with hypercoagulable ROTEM parameters including decreased CFT, increased alpha angle and increased MCF [35] while Davies et al noted that, compared to controls, patients with lung cancer have reduced CT, increased MCF and increased alpha angle [36].…”