Abstract

This review summarizes the evidence on antiphospholipid (aPL) antibodies and related thromboembolic events in patients with solid tumors. Data sources included Medline, EMBASE, Web of Science, PubMed ePubs, and the Cochrane Central Register of Controlled Trials through August 2019 without restrictions. Observational studies that evaluated patients with solid tumors for the presence of aPL antibodies were included. Data were extracted and quality was assessed by one reviewer and cross-checked by another. Thirty-three studies were identified. Gastrointestinal (GI) and genitourinary (GU) cancers were the most frequently reported. Compared with healthy patients, patients with GI cancer were more likely to develop anticardiolipin antibodies (risk ratio [RR], 5.1; 95% confidence interval [CI], 2.6-9.95), as were those with GU (RR, 7.3; 95% CI, 3.3-16.2) and lung cancer (RR, 5.2; 95% CI, 1.3-20.6). The increased risk for anti-β2-glycoprotein I or lupus anticoagulant was not statistically significant. Patients with lung cancer who had positive aPL antibodies had higher risk of developing thromboembolic events than those who had negative antibodies (RR, 3.8%; 95% CI, 1.2-12.2), while the increased risk in patients with GU cancer was not statistically significant. Deaths due to thromboembolic events were more common among patients with lung cancer who had elevated aPL antibodies. A limitation of this review is that the results are contingent on the reported information. We found an increased risk of developing aPL antibodies in patients with GI, GU, and lung cancers resulting in thromboembolic events and death. Further studies are needed to better understand the pathogenesis and development of aPL antibodies in cancer.

Introduction

Antiphospholipid syndrome (APS) is an acquired autoimmune prothrombotic disease characterized by persistent elevation of antiphospholipid (aPL) antibodies, lupus anticoagulant (LA), immunoglobulin G (IgG) and/or IgM isotype of anticardiolipin (aCL), or anti-β2-glycoprotein I (anti-β2-GPI) antibodies, leading to recurrent thromboembolic and pregnancy adverse events (abortion, fetal death, or premature birth).1-3  Multiple organ failure known as catastrophic APS occurs in ∼1% of patients with APS.4-6 

The prevalence of elevated aPL antibodies is 1% to 5% among healthy young individuals increasing to 50% among elderly patients with chronic diseases. However, it is unclear how many healthy people with positive antibodies eventually develop APS.7-11  A systematic review of observational studies excluding patients with autoimmune diseases reported a pooled prevalence rate of aPL antibodies in up to 23.3% of patients with stroke, 23% with myocardial infarction, 15.8% with deep vein thrombosis, and 13% of women with pregnancy adverse events.12  aPL antibodies develop in genetically susceptible individuals following an infection or in the setting of autoimmune diseases as a “first hit”; evidence suggests a “second hit” is also required for thrombosis to occur.13  Potential putative candidates for this second hit are infection, cancer, other procoagulant conditions, and certain drugs (eg, cytotoxic chemotherapy).14 

Patients with cancer are at increased risk of thrombosis (four- to 60-fold higher) compared with the general population.15,16  Elevation of aPL antibodies has been reported in various solid and hematological malignancies, suggesting a possible pathogenic role of aPL in triggering thrombosis in cancer patients.17-19  We conducted a systematic review and meta-analysis of observational studies evaluating the development of aPL antibodies and related thromboembolic events in patients with solid tumors.

Methods

Data sources and searches

Data sources included Medline, EMBASE, Web of Science, PubMed ePubs, and the Cochrane Central Register of Controlled Trials through August 2019 with no restrictions. The Medline search strategy is detailed in supplemental Appendix 1.

Study selection

Publications were screened by 6 independent reviewers (in pairs) using a 2-step approach. First, titles and abstracts were reviewed to identify relevant citations. Then, the full text of these citations was reviewed. Discrepancies were resolved by adjudication by a third reviewer.

We included observational studies reporting patients with solid tumors who were evaluated for aPL antibodies, measured at least once after the diagnosis of cancer. When multiple citations of the same study were published, we considered the most recent full text.

We excluded studies that reported patients with prior infection, autoimmune diseases, or surgery (eg, laparoscopy) and those receiving certain drugs (eg, interferon α) that could explain positive aPL antibodies. Studies were also excluded if they reported patients with prior history of thromboembolic/pregnancy events or elevated aPL antibodies diagnosed before the diagnosis of cancer, measured rare aPL subtypes not included in the diagnostic criteria of APS,1,2  or did not provide sufficient information about participants. Studies not published in English were excluded.

Data extraction and quality assessment

Data were extracted and quality was assessed by one reviewer (N.A.-W.) and cross-checked by another (F.F.). Disagreements were resolved by consensus. We extracted data on study characteristics (design, number of participants, type of cancer, subtype of aPL antibodies and isotype distribution, persistence of aPL antibodies, aPL-related thromboembolic or adverse pregnancy events, timing of aPL testing in relation to the clinical events, and related death). Because of the laboratory differences and variation in the cutoffs for aPL positivity, elevated titers were considered according to the study authors’ definition. When patients had >1 elevated aPL isotype, the overall prevalence was considered if the data were provided. Otherwise, the highest prevalent isotype was considered. Clinical features associated with APS (eg, thrombocytopenia) but not in the diagnostic criteria were not considered.1,2 

Risk of bias in individual studies was assessed using the Newcastle-Ottawa Scale in 3 key quality domains (selection, comparability of cohorts, and outcome); total maximum score is 9, and a higher score indicates a lower risk of bias.20 

Data synthesis and analysis

We performed a meta-analysis and estimated the risk ratios (RRs) with 95% confidence intervals (CIs) of developing aPL antibodies in patients with solid tumors compared with healthy controls via a random-effects model using RevMan version 5.3.21  We also estimated the RRs with 95% CIs of developing thromboembolic and/or pregnancy adverse events and related death in patients with solid tumors and positive aPL antibodies compared with patients with negative antibodies when data were available. Then, we pooled prevalence rates of aPL antibodies and related clinical events for each tumor type using STATA statistical software version 15 (STATA Statistical Software 2017: Release 15; STATA Corp., College Station, TX). Our numerators were the number of patients with solid tumors and positive aPL antibodies and/or aPL-related clinical events in each study. For the denominator, we considered all patients with solid tumors in each study. Statistical significance was set at 2-sided P < .05. Study heterogeneity was assessed by using the I2 statistic.

A funnel plot and a regression asymmetry test was performed to assess publication bias and small-study effects in the meta-analyses for having elevated aPL antibodies (aCL, LA, or anti-β2-GPI antibodies) in patients with solid tumors compared with healthy individuals.22 

Results

Study selection

Our search yielded 11 639 unique citations. Of these, 33 observational studies (40 publications) met eligibility criteria. The reasons for exclusion in each step are shown in supplemental Figure 1. References for selected studies are included in supplemental Table 1.

The publication bias graph is shown in supplemental Figure 2; Egger’s test showed no evidence for publication bias, even when outliers were removed.

Study characteristics

Of the 33 studies included, 31 reported the prevalence of aPL antibodies among patients with solid tumors, 11 also reported the prevalence among healthy controls as a comparison group, and 10 studies reported on the prevalence of thromboembolic and/or pregnancy events. Eighteen studies (54.5%) were prospective, 11 (33.3%) cross-sectional, and 4 (12.1%) retrospective cohort studies. Gastrointestinal (GI) tumors were the most frequently evaluated in 11 studies (33.3%), followed by genitourinary (GU) in 9 studies (27.3%). Twelve studies reported the stage of malignancy and/or the presence of metastasis; 1 reported that 80% of patients diagnosed with thromboembolism at presentation had distant metastasis at the same time.23  A total of 2773 patients with solid tumors were included (871 with GU, 428 with GI, 414 with breast, 353 with lung, 136 with melanoma, 19 with bone/soft tissue, 16 with head and neck, 11 with central nervous system [CNS], and 525 with various types of solid tumors); 877 healthy controls were evaluated. The most frequent aPL antibodies examined were aCL (19 studies; 57.6%), followed by anti-β2-GPI antibodies in 8 studies (24.2%) and LA in 7 (21.2%). Most studies used the 5th percentile as the cutoff for aCL and the 99th percentile as the cutoff for anti-β2-GPI; 11 studies did not report cutoffs used (supplemental Tables 2 and 3). Ten studies evaluated aPL antibodies but did not specify the antibody subtype. At least 2 aPL subtypes were examined in 8 studies (24.2%), and all 3 antibodies were examined in 2 studies.24,25 

Risk of developing aPL antibodies in patients with solid tumors compared with healthy controls (11 studies)

aCL antibodies.

A total of 235 patients with GI cancer were evaluated in 5 studies; patients were 5.1 times more likely than controls to develop aCL antibodies (95% CI, 2.6-9.95) (Table 1).26-30  Two studies included patients with GU cancer (n = 49) with increased pooled risk of developing aCL antibodies compared with healthy controls (RR, 7.3; 95% CI, 3.3-16.2).30,31  Pooled risk estimates from 2 studies evaluating 62 patients with breast cancer were not statistically significant (RR, 1.9; 95% CI, 0.19-19.9).30,32  One study evaluated patients with CNS, lung, and melanoma30 ; a significant higher risk was observed in patients with lung cancer compared with controls (RR, 5.2; 95% CI, 1.3-20.6), whereas in CNS and melanoma, the increased risk was not statistically significant. Two additional studies evaluated 165 patients with various solid tumors, reporting a significantly increased risk compared with controls (RR, 6.5; 95% CI, 2.1-20.3)25,30  (supplemental Figure 3).

Table 1.

Risk of developing elevated aCL, LA, and anti-β2-GPI antibodies between patients with solid tumors and healthy controls (n = 11 studies)

Cancer type (no. of studies)No. of positive patients /total (%)No. of positive controls /total (%)RR (95% CI)
Anticardiolipin antibodies    
 GI (n = 5)26-30  44/235 (18.7) 11/302 (3.6) 5.1 (2.6-9.95) 
 GU (n = 2)30,31  16/49 (32.7) 7/140 (5.0) 7.3 (3.3-16.2) 
 Breast (n = 2)30,32  3/62 (4.8) 4/137 (2.9) 1.9 (0.19-19.85) 
 CNS (n = 1)30  0/2 3/88 (3.4) 4.3 (0.28-65.0) 
 Lung (n = 1)30  5/28 (17.9) 3/88 (3.4) 5.2 (1.3-20.6) 
 Melanoma (n = 1)30  0/3 3/88 (3.4) 3.2 (0.20-51.7) 
 Various types of solid tumors (n = 2)25,30 * 8/165 (4.9) 4/346 (1.2) 6.5 (2.1-20.3) 
Anti-β2-GPI antibodies    
 GI (n = 2)26,33  9/119 (7.6) 6/153 (3.9) 1.7 (0.64-4.4) 
 Various types of solid tumors (n = 1)25 * 0/142 1/258 (< 1) 0.60 (0.02-14.7) 
LA    
 Various types of solid tumors (n = 1) 25 * 1/142 (< 1) 0/258 5.4 (0.22-132.5) 
Unspecified aPL antibodies    
 Breast (n = 1)34  19/77 (24.7) 6/137 (4.4) 5.6 (2.4-13.5) 
 GI (n = 1)34  7/21 (33.3) 6/137 (4.4) 7.6 (2.8-20.5) 
 GU (n = 1)35-39  32/134 (23.9) 0/20 10.1 (0.64-158.95) 
 Head and neck (n = 1)34  4/16 (25.0) 6/137 (4.4) 5.7 (1.8-18.1) 
 Lung (n = 1)34  2/8 (25.0) 6/137 (4.4) 5.7 (1.4-23.9) 
 Various types of solid tumor (n = 1) 25 * 2/142 (1.4) 2/258 (<1) 1.8 (0.26-12.8) 
Cancer type (no. of studies)No. of positive patients /total (%)No. of positive controls /total (%)RR (95% CI)
Anticardiolipin antibodies    
 GI (n = 5)26-30  44/235 (18.7) 11/302 (3.6) 5.1 (2.6-9.95) 
 GU (n = 2)30,31  16/49 (32.7) 7/140 (5.0) 7.3 (3.3-16.2) 
 Breast (n = 2)30,32  3/62 (4.8) 4/137 (2.9) 1.9 (0.19-19.85) 
 CNS (n = 1)30  0/2 3/88 (3.4) 4.3 (0.28-65.0) 
 Lung (n = 1)30  5/28 (17.9) 3/88 (3.4) 5.2 (1.3-20.6) 
 Melanoma (n = 1)30  0/3 3/88 (3.4) 3.2 (0.20-51.7) 
 Various types of solid tumors (n = 2)25,30 * 8/165 (4.9) 4/346 (1.2) 6.5 (2.1-20.3) 
Anti-β2-GPI antibodies    
 GI (n = 2)26,33  9/119 (7.6) 6/153 (3.9) 1.7 (0.64-4.4) 
 Various types of solid tumors (n = 1)25 * 0/142 1/258 (< 1) 0.60 (0.02-14.7) 
LA    
 Various types of solid tumors (n = 1) 25 * 1/142 (< 1) 0/258 5.4 (0.22-132.5) 
Unspecified aPL antibodies    
 Breast (n = 1)34  19/77 (24.7) 6/137 (4.4) 5.6 (2.4-13.5) 
 GI (n = 1)34  7/21 (33.3) 6/137 (4.4) 7.6 (2.8-20.5) 
 GU (n = 1)35-39  32/134 (23.9) 0/20 10.1 (0.64-158.95) 
 Head and neck (n = 1)34  4/16 (25.0) 6/137 (4.4) 5.7 (1.8-18.1) 
 Lung (n = 1)34  2/8 (25.0) 6/137 (4.4) 5.7 (1.4-23.9) 
 Various types of solid tumor (n = 1) 25 * 2/142 (1.4) 2/258 (<1) 1.8 (0.26-12.8) 
*

Cancer types included GI, GU, breast, lung, melanoma, head and neck, and other solid tumors.

Anti-β2-GPI antibodies.

Two studies measured these antibodies in patients with GI cancer,26,33  and 1 study measured them in patients with various solid tumors (Table 1).25  No statistically significant risk was observed when compared with healthy controls (supplemental Figure 4).

LA antibodies.

Font et al measured LA antibodies in patients with various solid tumors.25  Only 1 patient had LA, and the risk was not statistically significant when compared with controls.

Three additional studies evaluated the presence of aPL antibodies in different cancer types without specifying the antibodies subtype (Table 1).25,34-39  A statistically significant increased risk was observed in patients with breast, GI, head/neck, and lung cancers.

Pooled prevalence rates of developing aPL antibodies in patients with solid tumors (31 studies)

For this analysis, we included the prevalence of antibodies for all studies, with or without controls (Table 2). The pooled prevalence rates of the various types of cancer ranged between 7% and 28% for aCL antibodies,19,24-32,40-50  between 5% and 53% for anti-β2-GPI antibodies,24-26,33,40,42,44,45,51,52  and from 3% to 80% for LA.23-25,32,45,49,50,53,54  Two studies examined all 3 aPL antibodies, but none of them reported the percentage of patients who were positive for all 3; therefore, the pooled prevalence rate of triple-positive aPL antibodies could not be determined.24,25 

Table 2.

Pooled prevalence rates of developing aCL, LA, and anti-β2-GPI antibodies in patients with solid tumors (n = 31 studies)

Cancer type (no. of studies)No. of positive patientsNo. of total patientsPooled prevalence* (95% CI), %
Anticardiolipin antibodies    
 GI (n = 7)19,26-30,40  50 293 15 (8-24) 
 Breast (n = 5)30,32,40-42  35 220 9 (1-23) 
 GU (n = 5)30,31,40,43,44  111 457 26 (10-45) 
 Lung (n = 3)24,30,40,45  12 112 7 (2-14) 
 Melanoma (n = 3)30,46,47  136 0 (0-7) 
 Bone/soft tissue (n = 1)40  14 0 (0-22) 
 CNS (n = 2)30,40  11 0 (0-14) 
 Unspecified solid tumor (n = 4)25,30,48-50  42 227 28 (1-70) 
Anti-β2-GPI antibodies    
 GU (n = 4)40,44,51,52  59 476 8 (2-16) 
 Breast (n = 2)40,42  31 58 53 (39-66) 
 Lung (n = 2)24,40,45  23 85 24 (14-35) 
 Bone/soft tissue (n = 1)40  14 0 (0-22) 
 Central nervous system (n = 1)40  0 (0-30) 
 GI (n = 3)26,33,40  124 5 (1-10) 
 Unspecified solid tumor (n = 1)25  142 0 (0-3) 
LA    
 Lung (n = 2)24,45,53  147 314 47 (41-52) 
 Breast (n = 2)32,54  135 2 (0-5) 
 Bone/soft tissue (n = 1)23  80 (38-96) 
 GI (n = 1)54  33 3 (1-15) 
 Unspecified solid tumor (n = 2)25,49,50  22 181 6 (3-10) 
Unspecified aPL antibodies    
 Breast (n = 3)34,41,59  43 201 21 (16-27) 
 GU (n = 4)35,51,52,55,56  127 414 31 (22-41) 
 GI (n = 2)34,57  14 66 21 (11-31) 
 Lung (n = 1)34  25 (7-59) 
 Head and neck (n = 1)34  16 25 (10-49) 
 Unspecified solid tumor (n = 2)25,58  23 247 7 (4-11) 
Cancer type (no. of studies)No. of positive patientsNo. of total patientsPooled prevalence* (95% CI), %
Anticardiolipin antibodies    
 GI (n = 7)19,26-30,40  50 293 15 (8-24) 
 Breast (n = 5)30,32,40-42  35 220 9 (1-23) 
 GU (n = 5)30,31,40,43,44  111 457 26 (10-45) 
 Lung (n = 3)24,30,40,45  12 112 7 (2-14) 
 Melanoma (n = 3)30,46,47  136 0 (0-7) 
 Bone/soft tissue (n = 1)40  14 0 (0-22) 
 CNS (n = 2)30,40  11 0 (0-14) 
 Unspecified solid tumor (n = 4)25,30,48-50  42 227 28 (1-70) 
Anti-β2-GPI antibodies    
 GU (n = 4)40,44,51,52  59 476 8 (2-16) 
 Breast (n = 2)40,42  31 58 53 (39-66) 
 Lung (n = 2)24,40,45  23 85 24 (14-35) 
 Bone/soft tissue (n = 1)40  14 0 (0-22) 
 Central nervous system (n = 1)40  0 (0-30) 
 GI (n = 3)26,33,40  124 5 (1-10) 
 Unspecified solid tumor (n = 1)25  142 0 (0-3) 
LA    
 Lung (n = 2)24,45,53  147 314 47 (41-52) 
 Breast (n = 2)32,54  135 2 (0-5) 
 Bone/soft tissue (n = 1)23  80 (38-96) 
 GI (n = 1)54  33 3 (1-15) 
 Unspecified solid tumor (n = 2)25,49,50  22 181 6 (3-10) 
Unspecified aPL antibodies    
 Breast (n = 3)34,41,59  43 201 21 (16-27) 
 GU (n = 4)35,51,52,55,56  127 414 31 (22-41) 
 GI (n = 2)34,57  14 66 21 (11-31) 
 Lung (n = 1)34  25 (7-59) 
 Head and neck (n = 1)34  16 25 (10-49) 
 Unspecified solid tumor (n = 2)25,58  23 247 7 (4-11) 
*

Pooled prevalence is weighted by study size.

Cancer types included GI, GU, breast, lung, melanoma, head and neck, and other solid tumors.

Ten additional studies evaluated the presence of aPL antibodies in different cancer types but did not specify the antibody subtype.25,34,35,41,51,52,55-59  The highest pooled prevalence rate was 31% (22% to 41%) in patients with GU cancer.

Isotype distribution of aPL antibodies

Ten studies reported the isotype distribution of aCL antibodies in patients with solid tumors, and 3 included healthy controls.19,24-26,29,41-43,48,50  IgM was the most frequent isotype (87/601; 14.5%) compared with IgA (9/106; 8.5%) and IgG (41/532; 7.7%). Patients with breast and GI cancers had a significant increased risk of IgM compared with healthy controls (RR, 4.5; 95% CI, 1.1-18.9), while the increased risks of IgG (RR, 3.0; 95% CI, 0.44-20.8) and IgA (RR, 4.5; 95% CI, 0.52-39.7) were not statistically significant.

Four studies reported the isotype distribution of anti-β2-GPI antibodies; 2 of them included healthy controls.24-26,42  IgA was the most frequent isotype (33/130; 25.4%) compared with IgM (29/307; 9.4%) and IgG (8/309; 2.6%). A numerical nonsignificant increase in risk was observed in patients with breast and GI cancers compared with controls for all isotypes, but it did not reach statistical significance.

Follow-up and persistence of aPL antibodies

Four studies (12.1%) examined aPL antibodies in 2 consecutive occasions at least 12 weeks apart and the frequency of persistent positive antibodies was variable.24,25,30,41  One study evaluated patients with lung cancer every 6 months for up to 2 years, and there was no change in aPL positivity upon retesting, yet the number of patients who were tested more than once was not specified.24  Another study evaluated patients with breast cancer; all patients with positive IgM aPL (n = 20) and IgM aCL (n = 24) at baseline became negative after chemotherapy, while 4 out of 8 patients (50%) with positive IgG aPL and 8 out of 12 patients (33.3%) with positive IgG aCL at baseline remained positive.41  An additional study re-evaluated 3 patients (2 with colorectal and 1 with lung cancer) and reported that all 3 lost their positivity for aCL and remained thromboembolic-free for 12 months of follow-up.30  Only one study reported follow-up in 1 patient and 2 healthy controls who tested positive at baseline, but all 3 turned to be negative after 12 weeks.25 

Clinical events

Ten studies reported thromboembolic events. Of these, only 4 reported the events for patients with positive and with negative aPL antibodies (Table 3). Patients with lung cancer and positive aPL antibodies had a statistically significant higher risk of developing thromboembolic events compared with patients without aPL (RR, 3.8; 95% CI, 1.2-12.2).24,45,53  Two studies evaluated women with GU cancer for thromboembolic and/or pregnancy events and compared patients with positive and with negative aPL antibodies, but the increased risk was not statistically significant43,56  (supplemental Figure 5). One study reported deaths secondary to thromboembolic events in patients with lung cancer comparing those with positive and with negative aPL antibodies.53  Deaths were more frequent among those with aPL antibodies (RR, 2.1; 95% CI, 1.4-3.3).

Table 3.

Risk of developing thromboembolic and/or pregnancy events and related deaths in patients with solid tumors and positive aPL vs those with solid tumor and negative aPL antibodies (n = 4 studies)

Cancer type (no. of studies)No. of positive patients/patients with aPL antibodies (%)No. of patients with positive/negative aPL antibodies (%)RR (95% CI)
Thromboembolic/pregnancy events     
 Lung (n = 2)24,45,53  51/147 (34.7) 19/167 (11.4) 3.8 (1.2-12.2)  
 GU (n = 2)43,56  10/40 (25.0) 27/94 (28.7) 2.3 (0.11-47.9)  
Death due to thromboembolic events     
 Lung (n = 1)53  36/84 (42.9) 24/121 (19.8) 2.1 (1.4-3.3)  
Cancer type (no. of studies)No. of positive patients/patients with aPL antibodies (%)No. of patients with positive/negative aPL antibodies (%)RR (95% CI)
Thromboembolic/pregnancy events     
 Lung (n = 2)24,45,53  51/147 (34.7) 19/167 (11.4) 3.8 (1.2-12.2)  
 GU (n = 2)43,56  10/40 (25.0) 27/94 (28.7) 2.3 (0.11-47.9)  
Death due to thromboembolic events     
 Lung (n = 1)53  36/84 (42.9) 24/121 (19.8) 2.1 (1.4-3.3)  

The pooled prevalence rates of thromboembolic events for the various cancers ranged between 16% and 23% (Table 4). Both arterial and venous thrombosis was reported (stroke, transient ischemic attack, myocardial infarction, deep venous thrombosis, sinus venous thrombosis, arterial embolism, catheter thrombosis), as well as recurrent abortion. Few patients had >1 thromboembolic event. The pooled prevalence rates of thromboembolic events in patients with solid tumors and positive aPL antibodies was 35% (95% CI, 27% to 43%) for patients with lung cancer24,45,53  and 21% (95% CI, 8% to 38%) for GU cancer.43,56  One study examined all 3 aPL antibodies in patients who developed clinical events,24  another examined only 2 antibodies,50  and the remaining 8 examined only 1 subtype.23,43,51,53,55,56,60,61  LA was the most frequent antibody reported in 48% of patients who developed clinical events, followed by aCL (26.3%) and anti-β2-GPI (19.5%). Isotype distribution of aCL antibodies was reported in only 3 studies, and IgM was the most frequent (26.3%) compared with IgG (14.0%).24,43,50  As for anti-β2-GPI isotype, IgM (28.0%) was also more frequent than IgG (4.8%).24  Three additional studies evaluated the presence of aPL antibodies in patients with GU cancer but did not specify the antibody subtype; IgG was more frequent (36.5%) compared with IgM (19.0%) and IgA (48.3%).51,55,56 

Table 4.

Pooled prevalence rates of developing thromboembolic and/or pregnancy events and related deaths in patients with solid tumors (n = 10 studies)

Cancer type (no. of studies)No. of positive patientsTotal no. of patientsPooled prevalence* (95% CI), %
Thromboembolic/pregnancy events in patients with solid tumors (as reported in the entire sample)    
 Lung (n = 2)24,45,53  72 314 23 (18-28) 
 GU (n = 4)43,51,55,56  62 293 19 (12-28) 
 Bone/soft tissue (n = 1)23  19 122 16 (10-23) 
 Unspecified solid tumor (n = 3)49,50,60,61  44 232 22 (7-41) 
Thromboembolic/pregnancy events in patients with solid tumors who have positive aPL antibodies    
 Lung (n = 2)24,45,53  51 147 35 (27-43%) 
 GU (n = 2)43,56  10 40 21 (8-38) 
Death due to thromboembolic events in patients with solid tumors who have positive aPL antibodies    
 Lung (n = 1)53  36 84 43 (33-54) 
 Bone/soft tissue (n = 1)23  25 (5-70) 
Cancer type (no. of studies)No. of positive patientsTotal no. of patientsPooled prevalence* (95% CI), %
Thromboembolic/pregnancy events in patients with solid tumors (as reported in the entire sample)    
 Lung (n = 2)24,45,53  72 314 23 (18-28) 
 GU (n = 4)43,51,55,56  62 293 19 (12-28) 
 Bone/soft tissue (n = 1)23  19 122 16 (10-23) 
 Unspecified solid tumor (n = 3)49,50,60,61  44 232 22 (7-41) 
Thromboembolic/pregnancy events in patients with solid tumors who have positive aPL antibodies    
 Lung (n = 2)24,45,53  51 147 35 (27-43%) 
 GU (n = 2)43,56  10 40 21 (8-38) 
Death due to thromboembolic events in patients with solid tumors who have positive aPL antibodies    
 Lung (n = 1)53  36 84 43 (33-54) 
 Bone/soft tissue (n = 1)23  25 (5-70) 
*

Pooled prevalence is weighted by study size.

Of note, one study evaluated all 3 aPL antibodies as well as other immunologic and clotting factors (fibrinogen, factor VIII, factor IX, protein C, D dimmer, interleukin-6, and tumor necrosis factor levels) in 66 patients with lung cancer and identified only LA as a significant risk factor for increased thrombosis in a multivariable regression model.24  The same study evaluated aPL persistent positivity in lung cancer patients who developed thrombotic events and reported no change in aPL positivity in a 6-month interval. None of the studies reported the interval between positive aPL test result and occurrence of clinical events.

Risk of bias within studies

Overall Newcastle-Ottawa Scale scores ranged from 3 to 6 (supplemental Table 4). All studies reported adequately representative cohorts, but only 11 (33.3%) included healthy individuals from the same community and matched exposed and nonexposed participants. For the outcome domain, all studies assessed ≥1 aPL antibody, 22 (67%) specified the reference range used to define antibody elevation, and only 4 (12.1%) reported follow-up for aPL antibodies, and the duration of follow-up was enough to evaluate if the antibodies were persistent or transient.24,25,30,41  As for adequacy of follow-up, only 1 study reported follow-up for all participants who initially tested positive for aPL antibodies41 ; the follow-up rate was <80% in the other 3 studies, without description of those lost.24,25,30 

Discussion

Patients with cancer have an increased risk of thromboembolic events resulting in significant morbidity and mortality.16,62-65  Thromboembolic events are the second most common cause of death in cancer patients, occurring in up to 20%.65-67  The most widely used clinical tool for identification of risk of cancer venous thromboembolism (VTE) is the Khorana score.68  However, the clinical value of this score for thromboprophylaxis in cancer patients is uncertain.69  Moreover a recent meta-analysis of studies evaluating the Khorana score concluded that most of VTE events occurred outside the high-risk group.70  Therefore, there is an unmet need for newer tools incorporating other biomarkers to better identify cancer patients at high risk of VTE.71,72  There is no prediction model tool for cancer VTE that incorporates the risk associated with the presence of aPL in cancer patients.

To our knowledge, this is the first systematic review and meta-analysis to synthesize the evidence from observational studies evaluating the prevalence of aPL antibodies and associated thromboembolic events in patients with solid tumors. We pooled results from 33 studies, including 11 in which patients were compared with healthy controls. Pooled results showed an increased risk of developing aPL antibodies for almost all solid tumors examined when compared with controls, but for some cancers, the differences did not reach statistical significance, as samples were small. The highest risks were observed for GI, GU, and lung cancers. While many studies measured aCL antibodies, few examined anti-β2-GPI antibodies or LA, limiting potential inferences on causation, as these antibodies are important in the development of clinical events. No statistically significant association was observed between elevated LA or anti-β2-GPI antibodies and solid tumors, but the available evidence may not be sufficient to draw a definitive conclusion. Nevertheless, our data showed a high prevalence of all 3 aPL antibodies in various types of solid tumors. For instance, the pooled prevalence rates from all studies showed elevated aCL antibodies in more than one-fourth of patients with GU cancer, elevated anti-β2-GPI antibodies in more than half of patients with breast cancer, and positive LA antibodies in approximately half of patients with lung cancer.

The clinical significance of aPL antibodies in cancer patients and their potential impact on patients’ survival remain uncertain. To quantify the role of these antibodies in pathogenesis of thromboembolic events in patients with solid tumors, we evaluated the risk of thrombosis in cancer patients with aPL vs those without aPL. Few studies were identified showing a significant increased risk in patients with lung cancer, whereas the increased risk in GU cancer did not reach statistical significance, as the sample was small. Notably, LA seemed to be a significant risk factor for thrombosis in cancer, being positive in approximately half of the patients who developed clinical events. Only De Meis et al’s study was identified reporting persistent positive aPL in patients with lung cancer who developed thrombosis.24  However, most studies reported only 1 aPL titer, and none reported the interval between laboratory diagnosis of positive aPL and occurrence of thromboembolic events, so we cannot reach definitive conclusion regarding the attribution of clinical events to aPL antibodies. In an attempt to quantify the influence of elevated aPL antibodies on survival, we also evaluated thromboembolic event–related mortality in cancer patients with aPL vs those without aPL. Only Fei et al’s study was identified to show a higher mortality in patients with lung cancer and positive aPL antibodies.53 

Gomez-Puerta et al previously described the clinical and immunological profiles of 120 patients with cancer and positive aPL antibodies identified from the literature but had a more limited search (only one database) and included 45 cases with concomitant autoimmune diseases.17  Similarly, Islam documented 31 case reports where APS coexisted with cancer and reviewed observational studies reporting aPL antibodies in cancer.18  Both reviews identified the presence of aPL antibodies in different types of cancer and reported that aPL-related thromboembolic events could be the first manifestation of underlying cancer and that the presence of aPL could influence cancer treatment and prognosis. Nevertheless, it is important to note that in both reviews, cases diagnosed with cancer after the thrombotic manifestations of APS occurred were included. Moreover, the reviews did not follow the specific steps required for systematic reviews and did not pool the prevalence of aPL antibodies and related thromboembolic events or compare the results between cancer patients and controls.

aPL antibodies are well known as an acquired immune-mediated risk factor for thromboembolic events1,2,73 ; however, the exact mechanisms mediating the development of aPL antibodies in cancer are poorly understood. Conceivably. aPL antibodies could be produced as a humoral response against tumoral antigens. Also, some patients with monoclonal gammopathies may secrete immunoglobulins with aCL activity.30,46,74-77  Finally, the potential effect of cancer therapy is not well understood, but in the new era of immunotherapy, development of autoimmune antibodies is considered part of the spectrum of immune-related adverse events. Studies have shown that polymorphism mucin-like molecules such as P-selectin may contribute to the thrombotic risk of aPL.78  Several GI malignancies are mucin secreting, a known risk factor for thrombosis in cancer.79  However, specific tumor histologies were not consistently reported in the studies included in our review, and therefore, the effect of mucin-secreting tumors (adenocarcinomas) vs other types of tumors of the GI tract (ie, neuroendocrine) could not be assessed. Also, mucin-like substances are not routinely measured in the clinical setting for the assessment of thrombotic risk; hence, the effect of those biomarkers could not be incorporated in our review.

Other factors contribute to hypercoagulability in cancer, including activation of platelets and endothelial cells and enhanced expression of tissue factor, ultimately disrupting the coagulation cascade and fibrinolysis.80-82  In primary APS, in the presence of aPL antibodies, these mechanisms actively participate in triggering thrombosis.13,83,84  Yet, it is unclear how aPL antibodies may add to the preexisting risk of thrombosis in cancer patients. It is postulated that genetic factors play a role in susceptibility to thrombosis in cancer as well as primary APS.85,86  It should also be noted that the presence of aPL antibodies in cancer may carry additional risk as these antibodies could accelerate tumor angiogenesis and progression through a tissue factor–mediated effect.16,87  Moreover, whether the presence of aPL antibodies could increase the risk of developing immune-related adverse events in cancer patients treated with immunotherapies is still undetermined. Two patients with aPL antibodies induced by the use of checkpoint inhibitors have been reported, 1 with APS and the other without clinical manifestations88,89  In addition, aPL antibodies were observed in 18 of 30 patients with melanoma treated with interferon α and/or interleukin-2.46 

Our review included an extensive search of 5 databases and specific criteria for inclusion and quality appraisal. We excluded studies in which patients had thromboembolic events or elevated aPL antibodies before the diagnosis of cancer and studies reporting patients with concurrent autoimmune diseases or infection to avoid overestimating the risk of developing aPL antibodies and related thrombosis. Nevertheless, our review was limited by the data available in original studies. For instance, most studies did not assess all recommended aPL antibodies or used different cutoffs to define aPL antibody elevation, which might affect the interpretation of RR across subgroups. Moreover, most studies measured aPL antibodies on 1 occasion, did not report isotype distribution or measured only one isotype, and did not report the 3 aPL antibodies or isotype distribution in cancer patients who had thrombosis. Most studies did not specify the stage of cancer and whether cancer progression or specific therapies were associated with aPL and thrombosis, and therefore, we were not able to discern local vs locally advanced vs distant metastatic tumors, and further stratification on tumor histology and stage was not possible. No studies reported specifically whether any patients developed catastrophic APS. Data were pooled from different types of observational studies; few studies on specific malignancies had small sample sizes, and quality was a concern.

In conclusion, evidence in the literature supports an increased risk of developing aPL antibodies, primarily in patients with GI, GU, and lung cancers. Although it would be difficult to attribute clinical events to aPL antibodies drawn on 1 occasion, clinicians should be aware that these antibodies might contribute to developing thrombosis in cancer. While aPL positivity could help in predicting risk of thrombosis, the available evidence is not enough to recommend routine aPL testing for patients with solid tumors. Yet, aPL testing should be considered for patients presented with clots and should be repeated for any patients with positive aPL to determine if antibodies were clinically significant. Preclinical studies are warranted to help understanding the proposed mechanisms for aPL development and pathogenicity in cancer. Further well-designed longitudinal studies are crucial to evaluate the clinical outcomes of cancer patients developing these antibodies.

For data sharing, e-mail the corresponding author, Maria E. Suarez-Almazor (e-mail: msalmazor@mdanderson.org).

Acknowledgment

This study was supported in part by National Institutes of Health, National Cancer Institute grant P30 CA016672.

Authorship

Contribution: M.E.S.-A. had full access to all of the data in the study and takes responsibility for the integrity and the accuracy of the data analysis; M.E.S.-A., M.A.L.-O., and N.A.-W. contributed to study concept and design; M.E.S.-A., M.A.L.-O., J.H.T., and N.A.-W. acquired data; N.A.-W., M.A.L.-O., J.H.T., F.F., G.S., T.S., A.Y., and S.A.-H. analyzed and interpreted data; N.A.-W., F.F., and G.S. performed quality appraisals; N.A.-W. and M.E.S.-A. drafted the manuscript; M.E.S.-A., J.H.T., M.A.L.-O., C.M.R.-H., N.A.-W., F.F., G.S., T.S., A.Y., and S.A.-H. critically revised the manuscript for important intellectual content; N.A.-W. and M.A.L.-O. performed statistical analyses; and M.E.S.-A. provided administrative, technical, or material support and supervised the study.

Conflict-of-interest disclosure: The authors declare no competing financial interests.

Correspondence: Maria E. Suarez-Almazor, Department of Health Services Research, Unit 1444, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030; e-mail: msalmazor@mdanderson.org.

References

References
1.
Miyakis
S
,
Lockshin
MD
,
Atsumi
T
, et al
.
International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS)
.
J Thromb Haemost
.
2006
;
4
(
2
):
295
-
306
.
2.
Garg
N
,
Deodhar
A
.
The Sydney classification criteria for definite antiphospholipid syndrome
.
J Musculoskelet Med
.
2012
;
29
:
73
-
77
.
3.
Cervera
R
,
Piette
JC
,
Font
J
, et al;
Euro-Phospholipid Project Group
.
Antiphospholipid syndrome: clinical and immunologic manifestations and patterns of disease expression in a cohort of 1,000 patients
.
Arthritis Rheum
.
2002
;
46
(
4
):
1019
-
1027
.
4.
Cervera
R
,
Bucciarelli
S
,
Plasín
MA
, et al;
Catastrophic Antiphospholipid Syndrome (CAPS) Registry Project Group (European Forum On Antiphospholipid Antibodies)
.
Catastrophic antiphospholipid syndrome (CAPS): descriptive analysis of a series of 280 patients from the “CAPS Registry”
.
J Autoimmun
.
2009
;
32
(
3-4
):
240
-
245
.
5.
Asherson
RA
,
Cervera
R
,
de Groot
PG
, et al;
Catastrophic Antiphospholipid Syndrome Registry Project Group
.
Catastrophic antiphospholipid syndrome: international consensus statement on classification criteria and treatment guidelines
.
Lupus
.
2003
;
12
(
7
):
530
-
534
.
6.
Asherson
RA
,
Cervera
R
,
Piette
JC
, et al
.
Catastrophic antiphospholipid syndrome: clues to the pathogenesis from a series of 80 patients
.
Medicine (Baltimore)
.
2001
;
80
(
6
):
355
-
377
.
7.
Juby
AG
,
Davis
P
.
Prevalence and disease associations of certain autoantibodies in elderly patients
.
Clin Invest Med
.
1998
;
21
(
1
):
4
-
11
.
8.
Levine
JS
,
Branch
DW
,
Rauch
J
.
The antiphospholipid syndrome
.
N Engl J Med
.
2002
;
346
(
10
):
752
-
763
.
9.
Mchrani
T
,
Petri
M
. Epidemiology of the antiphospholipd syndrome. In:
Asherson
RA
, ed.
Handbook of Systemic Autoimmune Diseases
,
Amsterdam
:
Elsevier
;
2009
:
13
-
34
.
10.
Petri
M
.
Epidemiology of the antiphospholipid antibody syndrome
.
J Autoimmun
.
2000
;
15
(
2
):
145
-
151
.
11.
Shi
W
,
Krilis
SA
,
Chong
BH
,
Gordon
S
,
Chesterman
CN
.
Prevalence of lupus anticoagulant and anticardiolipin antibodies in a healthy population
.
Aust N Z J Med
.
1990
;
20
(
3
):
231
-
236
.
12.
Andreoli
L
,
Chighizola
CB
,
Banzato
A
,
Pons-Estel
GJ
,
Ramire de Jesus
G
,
Erkan
D
.
Estimated frequency of antiphospholipid antibodies in patients with pregnancy morbidity, stroke, myocardial infarction, and deep vein thrombosis: a critical review of the literature
.
Arthritis Care Res (Hoboken)
.
2013
;
65
(
11
):
1869
-
1873
.
13.
Koike
T
.
Antiphospholipid syndrome: 30 years and our contribution
.
Int J Rheum Dis
.
2015
;
18
(
2
):
233
-
241
.
14.
Shoenfeld
Y
,
Blank
M
,
Cervera
R
,
Font
J
,
Raschi
E
,
Meroni
PL
.
Infectious origin of the antiphospholipid syndrome
.
Ann Rheum Dis
.
2006
;
65
(
1
):
2
-
6
.
15.
Heit
JA
,
Silverstein
MD
,
Mohr
DN
,
Petterson
TM
,
O’Fallon
WM
,
Melton
LJ
III
.
Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study
.
Arch Intern Med
.
2000
;
160
(
6
):
809
-
815
.
16.
Sharma
BK
,
Flick
MJ
,
Palumbo
JS
.
Cancer-associated thrombosis: a two-way street
.
Semin Thromb Hemost
.
2019
;
45
(
6
):
559
-
568
.
17.
Gómez-Puerta
JA
,
Cervera
R
,
Espinosa
G
, et al
.
Antiphospholipid antibodies associated with malignancies: clinical and pathological characteristics of 120 patients
.
Semin Arthritis Rheum
.
2006
;
35
(
5
):
322
-
332
.
18.
Islam
MA
.
Antiphospholipid antibodies and antiphospholipid syndrome in cancer: uninvited guests in troubled times [published online ahead of print 24 July 2019]
.
Semin Cancer Biol
. doi:
10.1016/j.semcancer.2019.07.019
.
19.
Pugliese
L
,
Bernardini
I
,
Pacifico
E
,
Viola-Magni
M
,
Albi
E
.
Antiphospholipid antibodies in patients with cancer
.
Int J Immunopathol Pharmacol
.
2006
;
19
(
4
):
879
-
888
.
20.
Stang
A
.
Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses
.
Eur J Epidemiol
.
2010
;
25
(
9
):
603
-
605
.
21.
The Nordic Cochrane Center TCC
. Copenhagen, Denmark. http://community.cochrane.org/tools/review-production-tools/revman-5/revman-5-download. Accessed 15 November 2019.
22.
Sterne
JA
,
Egger
M
.
Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis
.
J Clin Epidemiol
.
2001
;
54
(
10
):
1046
-
1055
.
23.
Paz-Priel
I
,
Long
L
,
Helman
LJ
,
Mackall
CL
,
Wayne
AS
.
Thromboembolic events in children and young adults with pediatric sarcoma
.
J Clin Oncol
.
2007
;
25
(
12
):
1519
-
1524
.
24.
de Meis
E
,
Pinheiro
VR
,
Zamboni
MM
, et al
.
Clotting, immune system, and venous thrombosis in lung adenocarcinoma patients: a prospective study
.
Cancer Invest
.
2009
;
27
(
10
):
989
-
997
.
25.
Font
C
,
Vidal
L
,
Espinosa
G
, et al
.
Solid cancer, antiphospholipid antibodies, and venous thromboembolism
.
Autoimmun Rev
.
2011
;
10
(
4
):
222
-
227
.
26.
Battistelli
S
,
Stefanoni
M
,
Petrioli
R
, et al
.
Antiphospholipid antibodies and acute-phase response in non-metastatic colorectal cancer patients
.
Int J Biol Markers
.
2008
;
23
(
1
):
31
-
35
.
27.
Konstandoulakis
MM
,
Syrigos
KN
,
Leandros
M
,
Charalabopoulos
A
,
Manouras
A
,
Golematis
BC
.
Autoantibodies in the serum of patients with gastric cancer: their prognostic importance
.
Hybridoma
.
1998
;
17
(
5
):
431
-
435
.
28.
Nifosi
G
,
Bologna
E
,
Scassa
E
.
Anti-cardiolipin autoantibodies and gastrointestinal tract cancers
.
Thromb Haemost
.
1997
:
P2206-P
.
29.
Syrigos
KN
,
Charalampopoulos
A
,
Konstantoulakis
MM
,
Karayiannakis
A
,
Tsibloulis
V
,
Peveretos
P
.
Autoantibodies against cardiolipin in the serum of patients with colorectal adenocarcinoma: their prognostic significance
.
Eur Surg Res
.
1998
;
30
(
1
):
55
-
60
.
30.
Zuckerman
E
,
Toubi
E
,
Golan
TD
, et al
.
Increased thromboembolic incidence in anti-cardiolipin-positive patients with malignancy
.
Br J Cancer
.
1995
;
72
(
2
):
447
-
451
.
31.
Hokama
Y
,
Empey-Campora
C
,
Hara
C
, et al
.
Acute phase phospholipids related to the cardiolipin of mitochondria in the sera of patients with chronic fatigue syndrome (CFS), chronic Ciguatera fish poisoning (CCFP), and other diseases attributed to chemicals, Gulf War, and marine toxins
.
J Clin Lab Anal
.
2008
;
22
(
2
):
99
-
105
.
32.
Soliman
AA
,
Csorba
R
,
Ullrich
A
,
Tsikouras
P
,
Rath
W
,
von Tempelhoff
GF
.
Antiphopholipid antibodies and functional activated protein C resistance in patients with breast cancer during anthracycline-based chemotherapy administered through an intravenous port-catheter device
.
Clin Appl Thromb Hemost
.
2014
;
20
(
3
):
338
-
340
.
33.
Chio
LF
,
Oon
CJ
.
Changes in serum alpha 1 antitrypsin, alpha1 acid glycoprotein and beta 2 glycoprotein I in patients with malignant hepatocellular carcinoma
.
Cancer
.
1979
;
43
(
2
):
596
-
604
.
34.
Bazzan
M
,
Montaruli
B
,
Vaccarino
A
,
Fornari
G
,
Saitta
M
,
Prandoni
P
.
Presence of low titre of antiphospholipid antibodies in cancer patients: a prospective study
.
Intern Emerg Med
.
2009
;
4
(
6
):
491
-
495
.
35.
Abro
S
,
Clark
M
,
Barkan
G
, et al
.
Inflammation and hemostatic activation may contribute to postsurgical thrombosis in patients with bladder cancer
.
Clin Appl Thromb Hemost
.
2016
;
22
(
4
):
314
-
321
.
36.
Abro
S
,
Clark
M
,
Quek
M
, et al
.
Biomarker profiling of bladder cancer patients undergoing radical cystectomy: relevance of thrombotic and inflammatory processes [abstract]
.
Blood
.
2012
;
120
(
21
):
3405
.
Abstract 3405
.
37.
Abro
S
,
Clark
M
,
Quek
M
, et al
.
Biomarker profiling of bladder cancer patients undergoing radical cystectomy. Relevance of thrombotic and inflammatory processes
.
Hamostaseologie
.
2013
;
33
(
1
):
A79
.
38.
Clark
M
,
Quek
ML
,
Kahn
D
,
Hoppensteadt
D
,
Cunanan
J
,
Fareed
J
.
Biomarker profiling of bladder cancer patients undergoing radical cystectomy: relevance of thrombotic and inflammatory processes [abstract]
.
J Clin Oncol
.
2012
;
30
(
15 suppl
):
Abstract e15008
.
39.
Hoppensteadt
D
,
Clark
M
,
Quek
M
, et al
.
Biomarker profiling of bladder cancer patients undergoing radical cystectomy. Relevance of thrombotic and inflammatory processes
.
J Thromb Haemost
.
2013
;
11
:
984
-
985
.
40.
Taban
S
,
Ghiam
AF
,
Mosallaei
A
,
Bordbar
MR
,
Mannucci
PM
,
Karimi
M
.
Frequency of antiphosholipid antibodies in Iranian patients with solid malignancies: a pilot study
.
Iran J Immunol
.
2009
;
6
(
3
):
160
-
162
.
41.
Abdollahi
A
,
Omranipour
R
.
Is increase of homocysteine, anti-cardiolipin, anti-phospholipid antibodies associated with breast tumors?
Acta Med Iran
.
2015
;
53
(
11
):
681
-
685
.
42.
Richards
E
,
Himchak
E
,
Szymanski
J
,
Bivin
W
,
Lin
E
,
Liu
Q
.
Increased anti-phospholipid antibody titers in invasive ductal carcinoma Vs. ductal carcinoma in situ: Implications for surveillance
.
Lab Invest
.
2015
;
95
:
62A
.
43.
Samulak
D
,
Pisarska
M
,
Buks
J
,
Uchman
P
,
Sajdak
S
.
The clinical significance of Hughes’ syndrom in diagnostics of thromboembolism complications in a group of patients suffering from malignant genital organs cancer
.
Clin Exp Rheumatol
.
2007
;
25
(
2
):
130
.
44.
Vorobiev
A
,
Makatsaria
A
.
Inherent and acquired thrombophilia in cancer patient with thrombosis in past history
.
Thromb Res
.
2011
;
127
:
S149
.
45.
De Meis
E
,
Pinheiro
VR
,
Loures
MA
, et al
.
Lupus anticoagulant activity as a thrombosis risk factor in lung adenocarcinoma patients
.
Ann N Y Acad Sci
.
2007
;
1107
(
1
):
51
-
55
.
46.
Becker
JC
,
Winkler
B
,
Klingert
S
,
Bröcker
EB
.
Antiphospholipid syndrome associated with immunotherapy for patients with melanoma
.
Cancer
.
1994
;
73
(
6
):
1621
-
1624
.
47.
Bouwhuis
MG
,
Suciu
S
,
Collette
S
, et al;
EORTC Melanoma Group and the Nordic Melanoma Group
.
Autoimmune antibodies and recurrence-free interval in melanoma patients treated with adjuvant interferon
.
J Natl Cancer Inst
.
2009
;
101
(
12
):
869
-
877
.
48.
Bernardini
I
,
Pugliese
L
,
Magni
MV
,
Albi
E
.
Autoimmunity in the cancer
.
Clin Exp Rheumatol
.
2007
;
25
(
2
):
146
.
49.
Miesbach
WA
,
Asmelash
G
,
Puetz
B
,
Boehm
M
,
Scharrer
I
.
Manifestations of the antiphospholipid syndrome in patients with malignancies
.
Blood
.
2004
;
104
(
11
):
95B
-
96B
.
50.
Miesbach
W
,
Scharrer
I
,
Asherson
R
.
Thrombotic manifestations of the antiphospholipid syndrome in patients with malignancies
.
Clin Rheumatol
.
2006
;
25
(
6
):
840
-
844
.
51.
Grosse-Perdekamp
MT
,
Zarrabi
KK
,
Zarrabi
MH
.
Antiphospholipid (APL) antibodies in transitional cell carcinoma of the bladder: prevalence, specificity, and clinical significance
.
Blood
.
2001
;
98
(
11
):
71B
-
72B
.
52.
Makatsaria
A
,
Vorobiev
A
,
Volkova
V
.
Antiphospholipid antibodies spectrum in genital cancer patients with thrombosis in past history
.
Thromb Res
.
2007
;
120
:
S151
-
S151S
.
53.
Fei
X
,
Wang
H
,
Jiang
L
,
Zhao
T
,
Cheng
M
,
Yuan
W
.
Clinical and prognostic significance of lupus anticoagulant measurement in patients with lung cancer
.
Technol Cancer Res Treat
.
2017
;
16
(
6
):
1533034617714150
.
54.
Carvalho Dos Reis
JA
,
Marques Valido
FF
.
Lupus anticoagulant evaluation in pre-operative breast cancer and colorectal carcinoma patients
.
Clin Chem Lab Med
.
2015
;
53
:
S902
.
55.
Majdan
A
,
Dryglewska
M
,
Kotarski
J
,
Majdan
M
.
Does the presence of classic and novel antiphospholipid antibodies influence the risk of thrombosis development in patients with uterine malignancies?
Ann Rheum Dis
.
2019
;
78
(
suppl 2
):
391
.
56.
Makatsaria
A
,
Gris
JC
,
Vorobev
A
, et al
.
Antiphospholipid antibodies and obstetric complications as a risk factors for thrombotic complications in women with cancer
.
Res Pract Thromb Haemost
.
2019
;
3
(
suppl 1
):
679
-
680
.
57.
Kaźmierczak
M
,
Lewandowski
K
,
Wojtukiewicz
MZ
, et al
.
Cancer procoagulant in patients with adenocarcinomas
.
Blood Coagul Fibrinolysis
.
2005
;
16
(
8
):
543
-
547
.
58.
Mortazavizadeh
MR
,
Sadeghmanesh
R
.
Antiphospholipid antibodies in neoplastic patients
.
Iran J Cancer Prev
.
2009
;
2
(
2
):
63
-
66
.
59.
Abramson
N
,
Aster
RH
.
Retrospective assessment of hypercoagulability in breast cancer prevention trial
.
J Clin Oncol
.
2002
;
20
(
19
):
4133
-
4134
.
60.
Armas
JB
,
Dantas
J
,
Mendonça
D
, et al
.
Anticardiolipin and antinuclear antibodies in cancer patients—a case control study
.
Clin Exp Rheumatol
.
2000
;
18
(
2
):
227
-
232
.
61.
Ratcliffe
M
,
Broadfoot
C
,
Davidson
M
,
Kelly
KF
,
Greaves
M
.
Thrombosis, markers of thrombotic risk, indwelling central venous catheters and antithrombotic prophylaxis using low-dose warfarin in subjects with malignant disease
.
Clin Lab Haematol
.
1999
;
21
(
5
):
353
-
357
.
62.
Key
NS
,
Khorana
AA
,
Mackman
N
, et al
.
Thrombosis in cancer: research priorities identified by a National Cancer Institute/National Heart, Lung, and Blood Institute strategic working group
.
Cancer Res
.
2016
;
76
(
13
):
3671
-
3675
.
63.
Khalil
J
,
Bensaid
B
,
Elkacemi
H
, et al
.
Venous thromboembolism in cancer patients: an underestimated major health problem
.
World J Surg Oncol
.
2015
;
13
(
1
):
204
.
64.
Shaib
W
,
Deng
Y
,
Zilterman
D
,
Lundberg
B
,
Saif
MW
.
Assessing risk and mortality of venous thromboembolism in pancreatic cancer patients
.
Anticancer Res
.
2010
;
30
(
10
):
4261
-
4264
.
65.
Wun
T
,
White
RH
.
Epidemiology of cancer-related venous thromboembolism
.
Best Pract Res Clin Haematol
.
2009
;
22
(
1
):
9
-
23
.
66.
Elyamany
G
,
Alzahrani
AM
,
Bukhary
E
.
Cancer-associated thrombosis: an overview
.
Clin Med Insights Oncol
.
2014
;
8
:
129
-
137
.
67.
Khorana
AA
,
Francis
CW
,
Culakova
E
,
Kuderer
NM
,
Lyman
GH
.
Thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy
.
J Thromb Haemost
.
2007
;
5
(
3
):
632
-
634
.
68.
Khorana
AA
,
Kuderer
NM
,
Culakova
E
,
Lyman
GH
,
Francis
CW
.
Development and validation of a predictive model for chemotherapy-associated thrombosis
.
Blood
.
2008
;
111
(
10
):
4902
-
4907
.
69.
Agnelli
G
.
Direct oral anticoagulants for thromboprophylaxis in ambulatory patients with cancer
.
N Engl J Med
.
2019
;
380
(
8
):
781
-
783
.
70.
Mulder
FI
,
Candeloro
M
,
Kamphuisen
PW
, et al;
CAT-prediction collaborators
.
The Khorana score for prediction of venous thromboembolism in cancer patients: a systematic review and meta-analysis
.
Haematologica
.
2019
;
104
(
6
):
1277
-
1287
.
71.
Grilz
E
,
Marosi
C
,
Königsbrügge
O
, et al
.
Association of complete blood count parameters, d-dimer, and soluble P-selectin with risk of arterial thromboembolism in patients with cancer
.
J Thromb Haemost
.
2019
;
17
(
8
):
1335
-
1344
.
72.
Qdaisat
A
,
Soud
RA
,
Wu
CC
, et al
.
Poor performance of D-dimer in excluding venous thromboembolism among patients with lymphoma and leukemia
.
Haematologica
.
2019
;
104
(
6
):
e265
-
e268
.
73.
Radin
M
,
Schreiber
K
,
Sciascia
S
, et al
.
Prevalence of antiphospholipid antibodies negativisation in patients with antiphospholipid syndrome: a long-term follow-up multicentre study
.
Thromb Haemost
.
2019
;
119
(
12
):
1920
-
1926
.
74.
Thiagarajan
P
,
Shapiro
SS
,
De Marco
L
.
Monoclonal immunoglobulin M lambda coagulation inhibitor with phospholipid specificity. Mechanism of a lupus anticoagulant
.
J Clin Invest
.
1980
;
66
(
3
):
397
-
405
.
75.
Sanchez
A
,
Montaudie
H
,
Bory
P
, et al
.
Antiphospholipid syndrome following pembrolizumab treatment of stage IIIB unresectable melanoma
.
JAMA Dermatol
.
2018
;
154
(
11
):
1354
-
1356
.
76.
Gressier
L
,
Guilpain
P
,
Gorin
I
, et al
.
Skin necrosis revealing antiphospholipid syndrome during immunotherapy for melanoma
.
Acta Derm Venereol
.
2010
;
90
(
4
):
433
-
434
.
77.
Yasin
Z
,
Quick
D
,
Thiagarajan
P
,
Spoor
D
,
Caraveo
J
,
Palascak
J
.
Light-chain paraproteins with lupus anticoagulant activity
.
Am J Hematol
.
1999
;
62
(
2
):
99
-
102
.
78.
Diz-Kucukkaya
R
,
Inanc
M
,
Afshar-Kharghan
V
,
Zhang
QE
,
López
JA
,
Pekcelen
Y
.
P-selectin glycoprotein ligand-1 VNTR polymorphisms and risk of thrombosis in the antiphospholipid syndrome
.
Ann Rheum Dis
.
2007
;
66
(
10
):
1378
-
1380
.
79.
Borsig
L
,
Wong
R
,
Feramisco
J
,
Nadeau
DR
,
Varki
NM
,
Varki
A
.
Heparin and cancer revisited: mechanistic connections involving platelets, P-selectin, carcinoma mucins, and tumor metastasis [published correction appears in Proc Natl Acad Sci USA. 2001;98(9):5369]
.
Proc Natl Acad Sci USA
.
2001
;
98
(
6
):
3352
-
3357
.
80.
Lip
GYH
,
Chin
BSP
,
Blann
AD
.
Cancer and the prothrombotic state
.
Lancet Oncol
.
2002
;
3
(
1
):
27
-
34
.
81.
Prandoni
P
,
Falanga
A
,
Piccioli
A
.
Cancer and venous thromboembolism
.
Lancet Oncol
.
2005
;
6
(
6
):
401
-
410
.
82.
Gouin-Thibault
I
,
Achkar
A
,
Samama
MM
.
The thrombophilic state in cancer patients
.
Acta Haematol
.
2001
;
106
(
1-2
):
33
-
42
.
83.
Islam
MA
,
Alam
F
,
Sasongko
TH
,
Gan
SH
.
Antiphospholipid antibody-mediated thrombotic mechanisms in antiphospholipid syndrome: towards pathophysiology-based treatment
.
Curr Pharm Des
.
2016
;
22
(
28
):
4451
-
4469
.
84.
Schreiber
K
,
Sciascia
S
,
de Groot
PG
, et al
.
Antiphospholipid syndrome
.
Nat Rev Dis Primers
.
2018
;
4
(
1
):
18005
.
85.
D’Asti
E
,
Magnus
N
,
Meehan
B
,
Garnier
D
,
Rak
J
.
Genetic basis of thrombosis in cancer
.
Semin Thromb Hemost
.
2014
;
40
(
3
):
284
-
295
.
86.
Islam
MA
,
Khandker
SS
,
Alam
F
,
Kamal
MA
,
Gan
SH
.
Genetic risk factors in thrombotic primary antiphospholipid syndrome: A systematic review with bioinformatic analyses
.
Autoimmun Rev
.
2018
;
17
(
3
):
226
-
243
.
87.
Wu
YY
,
V Nguyen
A
,
Wu
XX
, et al
.
Antiphospholipid antibodies promote tissue factor-dependent angiogenic switch and tumor progression
.
Am J Pathol
.
2014
;
184
(
12
):
3359
-
3375
.
88.
Gupta
A
,
Shah
U
,
Khine
H
,
Vandergriff
T
,
Froehlich
T
.
Antiphospholipid syndrome associated with combined immune checkpoint inhibitor therapy
.
Melanoma Res
.
2017
;
27
(
2
):
171
-
173
.
89.
Aburahma
A
,
Aljariri Alhesan
N
,
Elounais
F
,
Abu Sitta
E
.
Antiphospholipid antibody induced by nivolumab
.
Case Rep Hematol
.
2018
;
2018
:
3106852
.

Author notes

*

F.F. and G.S. contributed equally to this study.

The full-text version of this article contains a data supplement.

Supplemental data