Pfrepper Christian
Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany.
Visc Med. 2020 Aug;36(4):280-287. doi: 10.1159/000509150. Epub 2020 Jul 15.
Venous (VTE) and arterial thromboembolism (ATE) are frequent complications of cancer. Risk assessment models (RAM) for stratification of the thrombotic risk in patients with gastrointestinal (GI) cancer have several limitations.
While pancreatic and stomach cancer are considered very high risk in all RAM, the risk of colorectal cancer differs between RAM, and esophageal cancer and cholangiocarcinoma were underrepresented or not included in any RAM. In addition, up to 49% of patients with pancreatic cancer develop splanchnic vein thrombosis (SVT). Prophylaxis with low-molecular-weight heparins (LMWH) in ambulatory cancer patients is associated with a positive risk-benefit ratio only in high-risk patients and LMWH have been the standard of care for the treatment of cancer-associated VTE and SVT over the last years. Direct oral anticoagulants (DOAC) have been shown to be equally effective compared to LMWH, but bleedings from the GI tract are more frequent. Therefore, recent guidelines suggest the use of DOAC for VTE treatment and for prophylaxis in ambulatory patients at high risk for VTE, but patients at high risk for bleeding, especially with active luminal cancer, should receive LMWH.
This review discusses RAM and the current options for prophylaxis and treatment of cancer-associated ATE, VTE, and SVT focusing on GI cancers.
静脉血栓栓塞（VTE）和动脉血栓栓塞（ATE）是癌症常见的并发症。用于胃肠道（GI）癌患者血栓形成风险分层的风险评估模型（RAM）存在若干局限性。
虽然在所有RAM中胰腺癌和胃癌都被视为高风险，但不同RAM对结直肠癌风险的评估有所不同，且食管癌和胆管癌在任何RAM中所占比例过低或未被纳入。此外，高达49%的胰腺癌患者会发生内脏静脉血栓形成（SVT）。在门诊癌症患者中，仅在高风险患者中使用低分子量肝素（LMWH）进行预防才具有正的风险效益比，并且在过去几年中LMWH一直是治疗癌症相关VTE和SVT的标准治疗方法。直接口服抗凝剂（DOAC）已被证明与LMWH同样有效，但胃肠道出血更为常见。因此，最近的指南建议在VTE治疗以及门诊VTE高风险患者的预防中使用DOAC，但出血高风险患者，尤其是患有活动性腔内癌症的患者，应接受LMWH治疗。
本综述讨论了RAM以及目前针对癌症相关ATE、VTE和SVT的预防和治疗选择，重点关注胃肠道癌症。
