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  • The primary cancer lesion was mostly in the uterus and

    2021-10-15

    The primary cancer lesion was mostly in the uterus and adnexa, followed by the gastrointestinal tract, brain, blood, and kidney and Science Daily (Fig. 2A). Histopathological findings indicated that most cancers were adenocarcinomas, followed by squamous cell carcinomas, glioblastomas, malignant lymphomas, and renal cell carcinomas (Fig. 2B). The prevalence of PE was comparable in both groups. A non-cancer patient who had previously undergone liver transplantation for liver cirrhosis 6 years earlier had portal vein thrombosis, which is indicated by “others” in Fig. 3A. The number of patients with thrombosis in upper sites tended to be higher in cancer than non-cancer patients; however, the site of DVT was not significantly different between the two groups (p=0.394, Fig. 3B). According to the edoxaban package insert and the HOKUSAI VTE trial protocol [19], edoxaban therapy should be preceded by parenteral anticoagulant therapy. However, in the present study, 37.5% of non-cancer patients and 55.7% of cancer patients did not use parenteral anticoagulants before edoxaban (Fig. 4A). The types of pretreatment did not differ significantly between the two groups. Administration of edoxaban without pretreatment was significantly more common in patients with only DVT, while parenteral anticoagulant pretreatment was more often used in PE cases (Fig. 4B and C). Recurrence of VTE, presenting as symptomatic DVT, developed in a non-cancer patient who had taken edoxaban for approximately 1 year and stopped it temporarily. In contrast, there was no recurrence of VTE in cancer patients, indicating no significant difference between the two groups (Fig. 5A). Clinically relevant bleeding occurred in three non-cancer (4.7%) and five cancer patients (8.2%). Among them, gastrointestinal bleeding occurred in two patients in each group. The incidence of clinically relevant bleeding did not differ significantly between the two groups (Fig. 5B). During the observation period, 21 patients, all of whom had cancer, died; 17 of them died from cancer. Therefore, the mortality rate was significantly higher in cancer than in non-cancer patients (Fig. 5C). Seventeen cancer and five non-cancer patients were classified as “uncertain” patients, since their outcomes were unknown. These events are listed in Table 2. In terms of changes in thrombus amount, 89.6% and 94.1% of non-cancer and cancer patients, respectively, showed normalization or improvement in the thrombus, with no significant differences between the two groups (Fig. 6A). The interval between the two imaging tests used to assess response to treatment was longer in normalized and improved patients (median duration: 66–85 days) than in unchanged patients (median duration: 10–28 days) (Fig. 6B). None of the patients experienced thrombus deterioration during edoxaban therapy. The differences of characteristics of patients included in this part of the analysis were not significantly different between non-cancer and cancer patients, except for the values of hemoglobin (11.6±2.4g/dl vs. 10.5±1.9g/dl, respectively, p=0.032) and hematocrit (34.4±6.7% vs. 31.6±5.2%, respectively, p=0.048).
    Discussion The high incidence of VTE and its recurrence in cancer patients is well-known. The pathogenesis of cancer-associated coagulopathy is complex and involves various mechanisms [24]. Tumor cells themselves can activate blood coagulation through multiple mechanisms, including production of procoagulant and fibrinolytic and pro-aggregating activities [17]. The hemostatic side effects of oncological treatments, including cytotoxic drugs, hormone therapy, anti-angiogenetic therapy, radiotherapy, and surgery, also contribute to blood coagulopathies [25]. In addition, the background characteristics of patients, including a history of prior thrombotic events, comorbid conditions, genetic factors, immobility, age, sex, and race are also risk factors for hypercoagulability. Thus, multiple factors may contribute to the development of VTE in cancer patients.