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

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


  • 46 Views
  • Uploaded on
  • Presentation posted in: General

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

THROMBOTIC COMPLICATIONS OF PANREATIC CANCER: A CLASSICAL KNOWLEDGE REVISITED

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

D. L. DUMITRASCU,

O. SUCIU,

C. GRAD,

D. GHEBAN

2ND MEDICAL DEPT.

UMPh IULIU HATIEGANU CLUJ

ROMANIA


Cluj, Romania


Armand Trousseau (1801­1867)


Looking for this association and its consequences for clinical practice


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

    • Trousseau

      1865


Jaundice

Pancreas CC

Thrombosis of aorta


Pancreatic CC

Thrombosis

Pancreas


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


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


Epidemiology

  • 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:

  • 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


Localisation of cancer


PathogenesisVirchow’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


Pathogenesis

  • 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

  • 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


Pathogenesis

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

  • 2% population, RR 2.0


Pathogenesis

  • 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 mechanisms

  • Extrinsec compression

  • Vascular invasion


TrousseauSyndrome


PANCREATIC CARCINOMA and DVT

  • 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

<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

  • 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

  • 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

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


Prophylaxis

  • 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

  • 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

  • Is pancreatic cancer associated with DVT?

  • YES

  • NO


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

  • YES

  • NO


ad
  • Login