Division of Hematology, Massachusetts General Hospital, Boston, MA.
Harvard Medical School, Boston, MA; and.
Hematology Am Soc Hematol Educ Program. 2019 Dec 6;2019(1):71-79. doi: 10.1182/hematology.2019000369.
The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult, because management of cancer-associated thrombosis requires anticoagulation despite known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.
恶性肿瘤与血栓之间的关联已经被认识了一个多世纪半。与无恶性肿瘤的患者相比，由于癌症和患者自身因素，癌症患者初次和复发性静脉血栓栓塞症（VTE）的风险增加。尽管进行了抗凝治疗，复发性 VTE 仍很常见，这给治疗带来了额外的挑战。与无癌症的患者相比，癌症患者在使用抗凝剂时出血的风险也增加。由于血液恶性肿瘤患者和接受强化骨髓抑制化疗方案治疗的患者常见血小板减少症，这种出血风险会进一步升高。尽管过去 15 年来癌症靶向治疗取得了进展，但许多大型研究证实，癌症患者的出血和 VTE 复发率仍然很高。由于癌症相关血栓形成的管理需要抗凝治疗，尽管已知出血风险增加，但在这些患者中平衡血栓形成和出血的风险会很困难。在具有挑战性的病例中，本篇综述将描述在数据有限的情况下的临床处理方法：尽管进行了抗凝治疗但仍有复发性 VTE 的癌症患者，以及在严重血小板减少症情况下发生新的 VTE 的癌症患者。
