Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy.
Hospital General Universitario Gregorio Marañón, Madrid, Spain.
Intern Emerg Med. 2023 Sep;18(6):1619-1634. doi: 10.1007/s11739-023-03306-8. Epub 2023 May 25.
Up to 15-20% of cancer patients experience one or more episodes of venous thromboembolism during cancer disease. Approximately 80% of all cancer-associated venous thromboembolic events occur in non-hospitalized patients. Routine thromboprophylaxis for outpatients with cancer who start new anticancer treatment is currently not recommended by the international guidelines due to the high heterogeneity of these patients in terms of VTE or bleeding risks, the difficulties in selecting patients at high risk, and the uncertainty of duration of prophylaxis. Although the international guidelines endorsed the Khorana score for estimating the thrombotic risk in ambulatory cancer patients, the discriminatory performance of this score is not completely convincing and varies according to the cancer type. Consequently, a minority of ambulatory patients with cancer receive an accurate screening for primary prophylaxis of VTE. The aim of this review is to provide support to physicians in identifying those ambulatory patients with cancer for whom thromboprophylaxis should be prescribed and those that should not be candidate to thromboprophylaxis. In absence of high bleeding risk, primary thromboprophylaxis should be recommended in patients with pancreatic cancer and, probably, in patients with lung cancer harboring ALK/ROS1 translocations. Patients with upper gastrointestinal cancers are at high risk of VTE, but a careful assessment of bleeding risk should be made before deciding on antithrombotic prophylaxis. Primary prevention of VTE is not recommended in cancer patients at increased risk of bleeding as patients with brain cancer, with moderate-to-severe thrombocytopenia or severe renal impairment.
多达 15-20%的癌症患者在癌症期间会经历一次或多次静脉血栓栓塞事件。所有与癌症相关的静脉血栓栓塞事件中，约有 80%发生在未住院的患者中。由于这些患者在 VTE 或出血风险方面存在高度异质性，在选择高风险患者方面存在困难，以及预防持续时间的不确定性，目前国际指南不建议对开始新的抗癌治疗的门诊癌症患者进行常规血栓预防。尽管国际指南支持 Khorana 评分来评估门诊癌症患者的血栓风险，但该评分的区分性能并不完全令人信服，并且根据癌症类型而有所不同。因此，少数门诊癌症患者接受了 VTE 一级预防的准确筛查。本综述的目的是为医生提供支持，以确定哪些门诊癌症患者需要进行血栓预防，哪些患者不适合进行血栓预防。在没有高出血风险的情况下，应建议患有胰腺癌的患者进行一级预防性抗凝治疗，可能还应建议患有携带 ALK/ROS1 易位的肺癌的患者进行一级预防性抗凝治疗。上消化道癌症患者发生 VTE 的风险很高，但在决定是否进行抗血栓预防之前，应仔细评估出血风险。不建议对有脑出血风险、血小板计数中度至重度降低或严重肾功能损害的癌症患者进行 VTE 的一级预防。
