Thrombotic complications of panreatic cancer a classical knowledge revisited
Download
1 / 30

THROMBOTIC COMPLICATIONS OF PANREATIC CANCER: A CLASSICAL KNOWLEDGE REVISITED - PowerPoint PPT Presentation


  • 54 Views
  • Uploaded on

THROMBOTIC COMPLICATIONS OF PANREATIC CANCER: A CLASSICAL KNOWLEDGE REVISITED. D. L . DUMITRASCU, O. SUCIU, C. GRAD, D. GHEBAN 2 ND MEDICAL DEPT. UMPh IULIU HATIEGANU CLUJ ROMANIA. Cluj, Romania. Armand Trousseau (1801­1867).

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' THROMBOTIC COMPLICATIONS OF PANREATIC CANCER: A CLASSICAL KNOWLEDGE REVISITED' - ria-knapp


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Thrombotic complications of panreatic cancer a classical knowledge revisited

THROMBOTIC COMPLICATIONS OF PANREATIC CANCER: A CLASSICAL KNOWLEDGE REVISITED

D. L. DUMITRASCU,

O. SUCIU,

C. GRAD,

D. GHEBAN

2ND MEDICAL DEPT.

UMPh IULIU HATIEGANU CLUJ

ROMANIA


Cluj romania

Cluj, Romania KNOWLEDGE REVISITED


Armand trousseau 1801 1867
Armand Trousseau KNOWLEDGE REVISITED(1801­1867)



  • clinical practiceIn conditions of cachexia, a special state of the blood occurs which predispose to spontaneous coagulation”

    • Trousseau

      1865


Jaundice clinical practice

Pancreas CC

Thrombosis of aorta


P clinical practiceancreatic CC

Thrombosis

Pancreas


longitudinal clinical practice and transversal section of popliteal vein: recent thrombosis, complete obstruction of popliteal vein


transversal clinical practice section of common femural vein at femural bifurcation: recent thrombosis, complet obstruction (duplex color)


Epidemiology
Epidemiology clinical practice

  • Incidence of thrombosis:

    • in cancer: 5-60%

  • 2x higher in cancer pts vs general population

  • 20% pts DVT have dg cancer


Clinical types of thrombosis
Clinical types of thrombosis clinical practice:

  • Superficial migratory thrombophlebitis (Trousseau syndrome)

  • Idiopathic deep venous thrombosis

  • Nonbacterial thrombotic endocarditis

  • Intravascular disseminated coagulation

  • Thrombotic microangiopathy (thrombocitary thrombocytopenic purpura and the hemolitic-uremic syndrome)

  • Arterial thrombosis


Localisat i on of cancer
Localisat clinical practiceion of cancer


Pathogenesis virchow s triad
Pathogenesis clinical practiceVirchow’s triad

  • Alterations in blood flow

  • Vascular endothelial injury

  • Alterations in the constituents of the blood

  • Patients with cancer : hypercoagulable state >> substances with procoagulant activity: tissue factor, cancer procoagulant


Pat h ogene sis
Pat clinical practicehogenesis

  • Hypercoagulability

    • Abnormal coagulation tests

    • Thrombine generated in excess

    • Tumour cells have direct procoagulant effect

    • Tissue factor activate F IX and FX initiating coagulation

    • Tumoral procoagulant: a Ca-dependent cistein-protease


Pathogenesis
Pathogenesis clinical practice

  • The factor V Leiden mutation, a mutation of the F5 gene (gene ID: 2153), causes partial resistance of this coagulation factor to the inactivating effects of activated protein C, a protein encoded by the PROC gene (gene ID: 5624)

  • 5% population RR 3-8


Pathogenesis1
Pathogenesis clinical practice

  • The prothrombin 20210A mutation found to be associated with elevated prothrombin levels

  • 2% population, RR 2.0


Pathogenesis2
Pathogenesis clinical practice

  • The endothelial cells may become procoagulant under the influence of proinflammatory cytokinases or other peptides: TNF & IL-1 increase the expression of adhesion molecules for leukocytes, PAF and tissue factor

  • TNF decreases the endothelial fibrinolytic activity, increases endothelial production of IL-1, increases the expression of thrombomoduline (which diminishes the activation of anticoagulant proteine C).


Other mec h anism s
Other clinical practicemechanisms

  • Extrinsec compression

  • Vascular invasion


Trousseau syndrome
Trousseau clinical practiceSyndrome


Pancreatic carcinoma and dvt
PANCREATIC CARCINOMA and DVT clinical practice

  • N=202

  • Venous THROMBOSIS: 108.3 PER 1000 PATIENT-YEARS (~11%)

  • Thrombosis: 58.6-FOLD INCREASE

  • CHEMOTHERAPY: 4.8-FOLD

  • RADIOTHERAPY: 1.0

  • POSTOPERATIVE: 4.5-FOLD

  • METASTASIS: 1.9-FOLD

    Blom et al Eur. J. Cancer 410, 2006


Cancer in 1383 cases of phlebitis venography nordstrom et al bmj 1994
CANCER IN 1383 CASES OF PHLEBITIS VENOGRAPHY + clinical practiceNordstrom et al BMJ 1994

<6mo >6 mo

  • ALL CANCER 66 84

  • Oesophagus + stomac: 3 4

  • Intestinal 7 10

  • Liver 5 3

  • Gallbladder 5 1

  • PANCREAS 6 2


Sorensen et al nejm 1998
Sorensen et al NEJM 1998 clinical practice

  • 15,348 patients with DVT and 11,305 patients with pulmonary embolism

  • 1737 cases cancer in the cohort with deep venous thrombosis, compared with 1372 expected cases (standardized incidence ratio, 1.3);

  • Among the patients with pulmonary embolism, standardized incidence ratio was 1.3,

  • The risk was substantially elevated only during the first six months of follow-up and declined rapidly

  • 40% of patients given a diagnosis of cancer within one year after hospitalization for thromboembolism had distant metastases at the time of the diagnosis

  • Strong associations with cancers: pancreas, ovary, liver (primary hepatic cancer), brain.


Risk of Venous Thrombosis per Type of Malignancy for Patients With a Diagnosis of Malignancy Within 5 Years Before Diagnosis of Venous Thrombosis

Bloom et al 2005

Type of Malignancy

No. of Patients/No. of Control

Odds Ratio (95% CI)/Adjusted Odds Ratio(95% CI)

No malignancy 1.00 1.00

Men 1279 /1038

Women 1552/ 1024

Malignancy

All hematological cancer 37/ 1 26.2 (3.6-191.4)/ 28.0 (4.0-199.7)

Gastrointestinal malignancies

Bowel 46/ 2 16.8 (4.1-69.1)/ 16.4 (4.2-63.7)

Pancreas 2/ 0 ND ND

Stomach 2 /0 ND ND

Esophagus 2/ 0 ND ND

All gastrointestinal cancer 52/ 2 18.9 (4.6-77.8)/ 20.3 (4.9-83.0)


Risk factors
Risk factors Patients With a Diagnosis of Malignancy Within 5 Years Before Diagnosis of Venous Thrombosis

  • Advanced age

  • Caucasians

  • Comorbidities

  • History of DVT

  • Location of cancer

  • First 6 months after cc dx

  • Metastasis

  • Recent surgery, current hospitalization, chemotherapy, central venous catheters, sepsis.


Prognosis
Prognosis Patients With a Diagnosis of Malignancy Within 5 Years Before Diagnosis of Venous Thrombosis

  • Poorer in pts with cancer (incl. pancreatic cancer + DVT) vs cancer (including pancreatic cancer without DVT (Alcalay et al J Clin Oncol 2006)


Prophylaxis
Prophylaxis Patients With a Diagnosis of Malignancy Within 5 Years Before Diagnosis of Venous Thrombosis

  • LMWH 5000 iu once a day

    (Bergquist et al Br J Surg 1995)

  • LMWH superior to heparin

    (Mismetti et al Br J Surg 2001)

  • Long-term: 4 weeks postop. superior to 1 week

    (Rasmussen et al Blood 2003)


Conclusions
Conclusions Patients With a Diagnosis of Malignancy Within 5 Years Before Diagnosis of Venous Thrombosis

  • Pts with pancreatic cancer have higher risk to develop thrombotic events

  • This contribute to their morbitiy nd mortality

  • These complications should be actively searched in order to improve life expectancy and qol

  • Thromboprofilaxis of pts with pancreatic cancer refered to surgery or having catheters is very important


Questions
QUESTIONS Patients With a Diagnosis of Malignancy Within 5 Years Before Diagnosis of Venous Thrombosis

  • Is pancreatic cancer associated with DVT?

  • YES

  • NO


Shall we screen pts with dvt recurrent for occult malignancy including pancreatic cc
Shall we screen pts with DVT (recurrent) for occult malignancy including pancreatic cc?

  • YES

  • NO


ad