上胃腸道癌症病患的預防性抗凝血劑


  【24drs.com】雖然癌症本身增加了靜脈栓塞(VTE)風險,化療更進一步升高風險,專家們的一般共識是,證據還不足以建議對所有病患使用預防性抗凝血劑,不過,一直以來有所討論的是,對於某些特定類型癌症病患的使用。
  
  在第14屆世界胃腸道癌症研討會中,英國的兩組研究者提出了上胃腸道(UGI)惡性腫瘤病患的此一特殊案例。
  
  英國Hull & East Yorkshire NHS Trust腫瘤部Rajarshi Roy醫師表示,基於對胰臟癌病患的初期試驗結果,我們已經改變實務。「UK Fragem Trial」這項研究顯示,使用dalteparin作為預防性抗凝血劑顯著降低了以gemcitabine治療之胰臟癌病患的所有VTE風險(European Journal of Cancer. 2012;48;1283-1292)。
  
  基於這項研究結果,Roy醫師等人使用預防性dalteparin治療他們的胰臟癌病患,這類病患一直都是血栓的高風險族群。現在,他們提出將它擴展到其他UGI惡性腫瘤病患,因為這些病患也有VTE高風險。
  
  會議中發表的一篇壁報中,研究者報告指出,胃食道接合處(GOJ)癌症患者的VTE比率特別高。文獻中,此比率約為10%-13%,但是研究者提出的比率則是高達21.5%。他們的資料來自對65名GOJ病患的回溯分析,發現14名病患在進行或完成新輔助的含白金處方化療時發生VTE。其中,8名病患(12%)有肺栓塞、5名(8%)有下肢深部靜脈栓塞、1名有靜脈留置線之鎖骨下靜脈血栓。作者們指出,儘管有使用低分子量肝素治療,發生肺栓塞的4名病患在手術30天內死亡。
  
  Roy醫師建議,對於所有UGI惡性腫瘤病患,應該可以預防性使用抗凝血劑,他的團隊正提出在這個族群進行臨床試驗。他指出,當病患接受化療和/或放射線治療時,我們的選擇是在療程前預防性使用。
  
  英國普茲茅斯Queen Alexandra 醫院腫瘤內科的Caroline Chau等研究者提出類似的一個試驗,也發表了一篇回溯資料,研究對象是接受新輔助化療和手術的115名UGI惡性腫瘤病患,超過半數(59%)病患為食道癌、28%是GOJ癌症、13%是胃癌。
  
  Chau醫師等人報告指出,VTE 發生率為12.2%,7名病患發生肺栓塞,另外7人發生深部靜脈血栓。
  
  研究者指出,VTE病患的存活結果較差,至少在治療初期時如此;這與分析的其他變項,如年齡、性別、發病部位、組織學、腫瘤大小、包含的淋巴結等無關。
  
  Chau醫師等人結論指出,我們提出一個前瞻隨機控制研究,對接受新輔助化療治療UGI惡性腫瘤的門診病患使用預防性抗凝血劑。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6874&x_classno=0&x_chkdelpoint=Y
  

Prophylactic Anticoagulants in Upper GI Cancer Patients

By Zosia Chustecka
Medscape Medical News

July 2, 2012 — Although cancer itself elevates the risk for venous thromboembolism (VTE), and chemotherapy elevates it still further, the general consensus of expert opinion is that evidence is insufficient to recommend prophylactic use of anticoagulants in all patients. However, it has long been argued that a special case can be made for patients with certain types of cancer.

At the 14th World Congress of Gastrointestinal Cancers, held in Barcelona, Spain, 2 separate groups of researchers from the United Kingdom proposed that patients with upper gastrointestinal (UGI) malignancies represent such a special case.

"We have already changed our practice as a result of an earlier trial in pancreatic cancer patients," Rajarshi Roy, FRCR, from the department of oncology at the Hull & East Yorkshire NHS Trust, in Hull, United Kingdom, told Medscape Medical News. That study, the UK Fragem Trial, showed that prophylactic anticoagulation with dalteparin significantly reduced the risk for all VTE in pancreatic cancer patients being treated with gemcitabine (European Journal of Cancer. 2012;48;1283-1292).

As a result of that study, Dr. Roy and colleagues use prophylactic dalteparin to treat their patients with pancreatic cancer, which is notorious for being highly thrombogenic.

Now, they propose extending this to other patients with UGI malignancies, because these patients are also at high risk for VTE.

In a poster presentation at the meeting, investigators reported a particularly high rate of VTE in patients with gastroesophageal junction (GOJ) cancers. In the literature, this has been estimated at around 10% to 13%, but researchers reported a much higher rate of 21.5%. Their data were derived from a retrospective analysis of 65 patients with GOJ cancer, which found that 14 patients developed a VTE during or after completion of neoadjuvant chemotherapy with a platinum-containing regimen. Of these, 8 patients (12%) had a pulmonary embolism, 5 (8%) had lower limb deep vein thrombosis, and 1 had subclavian vein thrombosis with an indwelling venous line. Four of the patients who developed a pulmonary embolism died within 30 days of surgery, despite therapeutic anticoagulation with low molecular weight heparin, the authors note.

Dr. Roy commented to Medscape Medical News that there may be a case to be made for the use of prophylactic anticoagulation in all patients with UGI malignancies, and his team is proposing a clinical trial in this population. "One option is to use prophylaxis during the preoperative period when patients are receiving chemotherapy and/or radiotherapy," he added.

Also proposing such a trial was another group of UK researchers, led by Caroline Chau, from the department of medical oncology, at the Queen Alexandra Hospital, Portsmouth, United Kingdom. This group also presented a retrospective review of data, this time from 115 patients with upper GI malignancies who underwent neoadjuvant chemotherapy and surgery. More than half of these patients (59%) had cancer of the esophagus, 28% had GOJ cancer, and 13% had stomach cancer.

Dr. Chau and colleagues reported a 12.2% incidence of VTE, with 7 patients developing a pulmonary embolism and another 7 developing deep vein thrombosis.

"Patients who suffered a VTE have inferior outcomes in terms of survival, at least in the early stages of treatment," researchers note. This was independent of all other variables analyzed, including age, gender, disease site, histology, tumor size, and nodal involvement.

"We propose a prospective randomized controlled study of the use of prophylactic anticoagulation in outpatients receiving neoadjuvant chemotherapy for UGI malignancies," Dr. Chau and colleagues conclude.

14th World Congress on Gastrointestinal Cancer. Abstracts P-0012 and P-006. Presented June 29, 2012.

    
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