Use of Viscoelastography in Malignancy-Associated Coagulopathy and Thrombosis: A Review

Abstract

The relationship between malignancy and coagulopathy is one that is well documented yet incompletely understood. Clinicians have attempted to quantify the hypercoagulable state produced in various malignancies using common coagulation tests such as prothrombin time, activated partial thromboplastin time, and platelet count; however, due to these tests' focus on individual aspects of coagulation during one specific time point, they have failed to provide clinicians the complete picture of malignancy-associated coagulopathy (MAC). Viscoelastic tests (VETs), such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM), are whole blood analyses that have the advantage of providing information related to the cumulative effects of plasma clotting factors, platelets, leukocytes, and red cells during all stages of the coagulation and fibrinolytic processes. VETs have gained popularity in the care of trauma patients to objectively measure trauma-induced coagulopathy (TIC), but the utility of VETs remains yet unrealized in many other medical specialties. The authors discuss the similarities and differences between TIC and MAC, and propose a mechanism for the hypercoagulable state of MAC that revolves around the thrombomodulin–thrombin complex as it switches between activating the protein C anticoagulation pathway or the thrombin activatable fibrinolysis inhibitor coagulation pathway. Additionally, they review the current literature on the use of TEG and ROTEM in patients with various malignancies. Although limited research is currently available, early results demonstrate the utility of both TEG and ROTEM in the prediction of hypercoagulable states and thromboembolic complications in oncologic patients.

Basic principles of viscoelastic testing

“…The results of VET have been found to rapidly predict the results of standard coagulation assays including prothrombin time/activated partial thromboplastin time, platelet count, and fibrinogen levels. 2 VET can also assess some types of hypercoagulability, [3][4][5] depending on the activator used; VET is likely not sensitive to deficiencies of the natural anticoagulants such as antithrombin or protein C. VET is also a widely available assay to assess for hyperfibrinolysis (though it is not sensitive to all degrees of fibrinolysis). 6 VET thus offers a rapid in vitro description of the entire clotting process, from initiation to lysis.…”

Viscoelastic testing in oncology patients (including for the diagnosis of fibrinolysis): Review of existing evidence, technology comparison, and clinical utility

“…We describe the TEG and ROTEM basics and the history, methodology, and basic interpretation of the TEG/ROTEM [20][21][22][23][24][25][26][27][28][29][30][31][32][33] . For the purposes of this discussion, we will present a simplified interpretation of the TEG/ROTEM with Figures 1 and 2.…”

“…Similarly, several theories exist to describe malignancy associated coagulopathy (MAC). 33 Unlike the acute onset in TIC, patients with MAC usually have an insidious development of coagulation disequilibrium from the dysregulation of endothelium, platelets, and coagulation factors. Because thromboembolism in TIC is commonly noted in the literature, it is a useful comparison with MAC for monitoring and diagnosing patients who are at risk of MAC.…”

The Utilization of Viscoelastic Testing to Guide Blood Component Therapy and Adjunctive Hemostatic Therapy for Postpartum Hemorrhage: A Narrative Review

“…The normal or physiologic TEG tracing is shown in Figure 2. The TEG tracing parameters are abbreviated as follows: the time to reach an amplitude of 2 mm is reaction time (R), the time to create a certain level of clot is kinetics or clot formation (K), the rate of clot formation is the α-angle, the maximum clot strength is maximum amplitude (MA), and the percent decrease in maximum amplitude after 30/60 minutes is lysis at 30/60 minutes (LY30/60) [35][36][37][38][39][40][41][42].…”