Epidemiology, biology, and management of venous thromboembolism in gliomas: An interdisciplinary review.
Epidemiology, biology, and management of venous thromboembolism in gliomas: An interdisciplinary review.
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DOI：
10.1093/neuonc/noad059
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发表时间：
2023-04
期刊：
影响因子：
15.9
通讯作者：
J. Jo;M. Diaz;C. Horbinski;N. Mackman;S. Bagley;M. Broekman;J. Rak;J. Perry;I. Pabinger;N. Key;D. Schiff
中科院分区：
文献类型：
--
作者：
J. Jo;M. Diaz;C. Horbinski;N. Mackman;S. Bagley;M. Broekman;J. Rak;J. Perry;I. Pabinger;N. Key;D. Schiff
弥漫性胶质瘤患者在疾病过程中发生静脉血栓栓塞（VTE）的风险很高，胶质母细胞瘤（GBM）患者的发生率高达30%，低级别胶质瘤患者的风险较低，但不可忽略。最近和正在进行的确定风险增加患者的临床和实验室生物标志物的努力提供了希望，但迄今为止，围手术期以外的预防作用尚未得到证实。新出现的数据表明异柠檬酸脱氢酶（IDH）野生型胶质瘤患者发生静脉血栓栓塞的风险更高，IDH突变在抑制促凝剂组织因子和足素产生中的潜在机制作用。根据已发表的指南，建议在没有胃肠道或泌尿生殖系统出血风险增加的患者中使用低分子肝素（LMWH）或直接口服抗凝剂（DOACs）进行治疗性抗凝治疗。由于GBM颅内出血（ICH）的风险升高，抗凝治疗仍然具有挑战性，有时令人担忧。关于脑出血与低分子肝素在胶质瘤患者中的风险存在矛盾的数据；小型回顾性研究表明，doac可能比低分子肝素带来更低的脑出血风险。正在研究的抗凝剂，如因子XI抑制剂，在不影响止血的情况下预防血栓形成，可能具有更好的治疗指标，有望进入癌症相关血栓形成的临床试验。
Patients with diffuse glioma are at high risk of developing venous thromboembolism (VTE) over the course of the disease, with up to 30% incidence in patients with glioblastoma (GBM) and a lower but nonnegligible risk in lower-grade gliomas. Recent and ongoing efforts to identify clinical and laboratory biomarkers of patients at increased risk offer promise, but to date, there is no proven role for prophylaxis outside of the perioperative period. Emerging data suggest a higher risk of VTE in patients with isocitrate dehydrogenase (IDH) wild-type glioma and the potential mechanistic role of IDH mutation in the suppression of production of the procoagulants tissue factor and podoplanin. According to published guidelines, therapeutic anticoagulation with low molecular weight heparin (LMWH) or alternatively, direct oral anticoagulants (DOACs) in patients without increased risk of gastrointestinal or genitourinary bleeding is recommended for VTE treatment. Due to the elevated risk of intracranial hemorrhage (ICH) in GBM, anticoagulation treatment remains challenging and at times fraught. There are conflicting data on the risk of ICH with LMWH in patients with glioma; small retrospective studies suggest DOACs may convey lower ICH risk than LMWH. Investigational anticoagulants that prevent thrombosis without impairing hemostasis, such as factor XI inhibitors, may carry a better therapeutic index and are expected to enter clinical trials for cancer-associated thrombosis.