Abstract
Background: Clinical presentation of cancer-associated non-bacterial thrombotic endocarditis (Ca-NBTE) patients including type of malignancy, cardiac valves involved, type of thrombotic complications and hematological indices is limited to cases reports and one small clinical series.
Patients and Methods: An electronic search of Mayo Clinic clinical and laboratory records (03/31/2002-06/30/2022) with subsequent manual review was performed to identify adult patients with echocardiographically detected NBTE, diagnosis of active cancer, no infectious endocarditis or lupus anticoagulant/antiphospholipid antibodies.
Results: Ca-NBTE was diagnosed in 113 patients (mean age 63.3±9.7 years, 67.0% female). Majority of our patients had advanced cancer with 94 out of 107 (87.8%) with either stage IV (n=80) or stage III (n=14). Only 3 patients had stage I cancer. The most common origin of malignancy was lung cancer representing 42 cases (37.2%) and pancreatic cancer (n=19, 16.8%) followed by 15 cases (14.1%) of gynecological malignancies (including 9 ovarian, 4 endometrial, and 2 cervical cancers). Eight Ca-NBTE patients (7.1%) had gastrointestinal cancer equally distributed into upper and lower tract. Hematologic malignancy was diagnosed in 7 patients (6.2%) with 3 patients having myeloid malignancy and 4 lymphoid. Five patients in our cohort had two active cancers at the time of Ca-NBTE diagnosis. The predominant histological type of cancer was adenocarcinoma (n=80, 70.8 %). All pancreatic, over 90% of lung, near 90% of gastrointestinal, and almost half of genitourinary cancers were adenocarcinomas.
Vast majority of patients had thrombotic complications at the time of diagnosis with 92 (81.4%) patients with embolic complications to the brain, 10 (8.9%) to the spleen, 9 (8.0%) kidney, 6 (5.3) coronary and 3 (2.7%) to the extremities.
The platelet count ranged from 10 to 459 x 109/L with almost 50% of patients having thrombocytopenia (<150,000) at the time of Ca-NBTE diagnosis. There were no patients with creatinine clearance less than 30. Prior history of venous thromboembolism was noted in 61 (54.0%) patients of our cohort. Most often affected valve was mitral (n=68) followed by aortic (n=61). Only one heart valve was affected by Ca-NBTE in 93 patients (48 mitral, 42 aortic, and 3 tricuspid). Eighteen patients had Ca-NBTE affecting 2 valves (16 mitral and aortic, 1 mitral and tricuspid) with one patient having all 4 valves involved.
Of 104 anticoagulated patients, 76 received low molecular weight heparin, 16 apixaban, 22 unfractionated heparin, 16 warfarin, and 6 rivaroxaban.
Conclusion: Ca-NBTE is more common in female patients with underlying pulmonary and pancreatic cancers and will usually present with acute stroke. Mitral valve is the most common involved, but nearly 20% of patients had multiple valves involved. In our cohort most patients were treated with low molecular weight heparin.
Disclosures
No relevant conflicts of interest to declare.
Author notes
Asterisk with author names denotes non-ASH members.
