Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
Thromboelastography with Platelet Mapping to Identify Prothrombotic Coagulation Profiles in Select Patients
Hall R, Majumdar M, Cassidy R, et al. Use of Thromboelastography with Platelet Mapping to Identify Prothrombotic Coagulation Profiles in Patients with a History of Cardiac Intervention Undergoing Lower Extremity Revascularization. J Am Coll Surg. 2022, in press.
Patients with combined coronary artery and peripheral artery disease are at significant risk for major adverse limb events (MALE) related to thrombotic complications. Providing optimal anticoagulant management that reduces risk of MALE and minimizes risk of bleeding related to anticoagulation is an ongoing challenge for surgeons caring for these patients. Ryan Hall, MD, and coauthors used thromboelastography and platelet mapping (TEG-PM) preoperatively and during the first 6 months of postoperative follow up to define coagulation profiles in patients with combined vascular disease compared with patients with peripheral arterial disease alone.
The study evaluated 477 TEG-PM samples from 114 patients; the data analysis showed that patients with combined arterial disease had a more pronounced prothrombotic profile (lower platelet inhibition, higher platelet aggregation, and greater maximum clot strength) compared with patients who had only peripheral arterial disease. The prothrombotic profile was associated with increased risk of MALE.
The authors concluded that coagulation profiling with TEG-PM had potential value for improving anticoagulant management in high-risk patients.
Editorial
Chaudhary R, Neal MD. Platelet and Clot Characteristics to Guide Antithrombotic Management in Patients with Polyvascular Disease. J Am Coll Surg. 2022, in press.
In the editorial by Rahul Chaudhary, MD, MBA, and Matthew Neal, MD, FACS, that accompanied the article, the limitations of the study, especially small sample size, were noted. Despite these limitations, the editorialists emphasized that TEG-PM has the potential to provide a way for clinicians to obtain guidance that can lead to individualized anticoagulant management.
Considerations for the Use of Circulating Tumor DNA in Cancer Patients
Krebs MG, Malapelle U, Andre F, et al. Practical Considerations for the Use of Circulating Tumor DNA in the Treatment of Patients With Cancer: A Narrative Review. JAMA Oncol. Dec 1 2022;8(12):1830-1839. doi:10.1001/jamaoncol.2022.4457
Although tissue biopsy with tumor profiling and identification of genomic alterations that can be targets for specific therapeutic interventions remains the preferred approach, use of “liquid biopsy,” where blood samples are analyzed for tumor cells and/or specific substances such as tumor DNA is increasingly used for tumor profiling, screening, and guidance of therapy.
Tumor DNA analysis has been valuable in patients with lung cancer; this approach has been useful during postoperative follow up when tissue biopsy cannot be obtained. Circulating tumor DNA analysis can provide evidence to support early intervention or definitive localized intervention for management of tumors in postoperative patients.
The uses and challenges associated with use of “liquid biopsy” are clearly illustrated in the article. One limitation of blood sampling for tumor DNA is the presence of clonal hematopoiesis of indeterminate potential (CHIP). CHIP is a source of biologic noise that can cause variations in circulating DNA that are unrelated to the underlying tumor. These alterations are found in older patients with lung cancer, colorectal cancer, and other solid tumors. CHIP-related alterations can be detected and accounted for using peripheral blood mononuclear cell sequencing. The authors noted that analyses of circulating tumor DNA have significant potential for improving management of lung cancer and other tumors.
Efforts to increase clinical usage are needed and these will require collaboration and increased participation in clinical trials.
