Supportive Care in Pediatric Cancer: The Road to Prevention of Thrombosis

Abstract

The survival rate of children with cancer has increased impressively to almost 80% over the last decades as a result of improved diagnostic procedures and multimodal treatment strategies. Therefore, it becomes more and more important to prevent mortality and morbidity of treatment-associated complications, including venous thromboembolism (VTE). VTE occurs predominantly in children with acute lymphoblastic leukemia, lymphoma, and sarcoma. Pathogenesis of thrombosis in children with cancer is multifactorial. Thrombosis develops due to a combination of the primary disease itself, chemotherapy and supportive care, associated complications, and inherited prothrombotic risk factors probably contributed to the development of thrombosis in these children. Mortality as a result of VTE is low, but both symptomatic and asymptomatic thrombosis cause significant morbidity to justify primary thromboprophylaxis in children with cancer. Identification of risk factors is important to develop predictive models to identify patients at highest risk of thrombosis. Due to variations in risk factors, these models should be tailored to treatment protocols and patient populations. Multicenter studies are needed to investigate which prophylactic strategies are effective and safe to prevent thrombosis in children with cancer.

Thrombosis and Anticoagulant Therapy Among Pediatric Cancer Patients: Real-Life Data

“…The data on thromboprophylaxis in children with cancer is scarce [ 15 , 27 ]. Specifically, in ALL, three studies have evaluated the use of LMWH at the start of asparaginase treatment and until one week after the last dose.…”

“…However, to date, there have been no clear guidelines in pediatric cancer patients with regard to thromboprophylaxis. In addition, many pediatric oncologists are hesitant to use prophylactic anticoagulation in children with cancer because of the associated risk of bleeding, mostly due to pre-existing thrombocytopenia [ 15 ].…”

Prognostic Value of Fluorine-18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Imaging for Predicting Venous Thromboembolism in Children With Lymphoma

“…10,11 Specifically, chemotherapy induces vascular injury through recruitment of inflammatory mediators, toxic effects on endothelial cells, and generation of a procoagulant environment, 10,[12][13][14][15][16][17][18] which collectively promotes VTE risk. Patients are most prone to VTE immediately after the start of chemotherapy; 19 however, oncologists are often reluctant to use anticoagulants preventatively due to an already increased bleeding risk associated with cancer and chemotherapy-induced thrombocytopenia. 19 Therefore, anticoagulation is commonly used to treat, but not prevent, VTE in children with lymphoma.…”

“…Patients are most prone to VTE immediately after the start of chemotherapy; 19 however, oncologists are often reluctant to use anticoagulants preventatively due to an already increased bleeding risk associated with cancer and chemotherapy-induced thrombocytopenia. 19 Therefore, anticoagulation is commonly used to treat, but not prevent, VTE in children with lymphoma. Further, although thromboprophylaxis guidelines exist for patients with cancer [20][21][22][23][24] and several studies have evaluated VTE risk prediction models for children, [25][26][27][28][29] risk models are not widely used to guide anticoagulation in young patients who may be at high risk for VTE.…”