Thrombolysis treatment for submassive pulmonary thromboembolism in patients with cancer: a safe therapeutic tool

The number of cancer patients admitted to intensive care units (ICUs) around the world has increased with recent improvements in cancer therapies. Cancer is now recognized as a chronic disease that is associated with possible acute decompensation caused by cardiovascular, respiratory or infectious disorders, which makes treating these patients challenging. Pulmonary thromboembolism is a common cause of morbidity and mortality in cancer patients and is mainly caused by pulmonary hypertension and right ventricle dysfunction. A submassive embolism in a cancer patient may increase morbidity, delay anticancer therapy, and decrease the patient’s quality of life. A submassive pulmonary embolism is diagnosed when the patient presents right ventricle failure and pulmonary hypertension without hemodynamic instability. Treatment with thrombolytic agents during routine medical practice has altered the natural treatment course for massive and submassive pulmonary embolism. Thrombolysis is currently the standard treatment for patients with a massive thromboembolism, and this treatment is associated with a significant reduction in mortality. However, thrombolytic treatment for submassive embolisms remains controversial. Konstantinides et al published a study reporting better outcomes in patients with submassive pulmonary embolism that were treated with thrombolysis, including a decreased need for mechanical ventilation and vasopressor use, as compared to anticoagulation alone. However, in cancer patients, thrombolysis may be associated with an increased risk of bleeding. The incidences of coagulopathy, thrombocytopenia, and hemorrhagic disorders in cancer patients are significantly higher compared to patients without cancer, what results in a higher risk of fatal bleeding. For example, patients with brain metastasis of a solid tumor should never be treated with thrombolysis; thus, many cancer patients are ineligible for this treatment. Here, we describe four oncology patients with acute submassive pulmonary embolisms who were treated with alteplase and heparin. The aim of this study was to assess thrombolytic therapy in patients with a solid metastatic tumor, thereby assessing its potential therapeutic benefit in cancer patients with venous thromboembolism.