恶性肿瘤相关静脉血栓栓塞症的研究分析

Research Analysis of Cancer-Associated Venous Thromboembolism

摘要: 恶性肿瘤相关静脉血栓栓塞症(cancer-associated venous thromboembolism, CAT)是肿瘤患者治疗过程中重要的并发症，兼具高发生率、高复发风险与较高出血代价等特点。与普通人群相比，肿瘤患者的VTE发生风险显著增高，且CAT的发生与更差的肿瘤结局相伴随。CAT的病理生理基础并非单一因素所致，而是肿瘤促凝效应、炎症–凝血轴激活、血小板/内皮细胞功能异常以及纤溶抑制等多通路耦合的结果。近年来，随机对照试验与临床实践指南的持续更新推动了CAT管理策略的发展：低分子肝素(LMWH)长期作为治疗基石，直接口服抗凝药(DOACs)在多个关键研究中显示出与LMWH相当的疗效甚至潜在优势，但其安全性在不同肿瘤亚型与解剖部位之间呈现差异，提示需将出血风险与肿瘤相关因素纳入个体化决策。本文围绕CAT的流行病学与临床负担、机制框架、诊断路径及治疗策略(含预防与治疗、疗程与随访)进行系统归纳，并总结当前证据体系的主要争议点与未来研究方向。

Abstract: Cancer-Associated venous thromboembolism (CAT) is an important complication during the treatment of patients with malignant tumors. It is characterized by a high incidence, a high risk of recurrence, and a considerable risk of bleeding. Compared with the general population, patients with cancer have a significantly increased risk of VTE. The occurrence of CAT is also associated with poorer oncological outcomes. The pathophysiological basis of CAT is not driven by a single factor. Instead, it results from the interaction of multiple mechanisms, including tumor-related procoagulant activity, activation of the inflammation-coagulation axis, dysfunction of platelets and endothelial cells, and suppression of fibrinolysis. In recent years, continuous updates from randomized controlled trials and clinical practice guidelines have promoted the evolution of CAT management strategies. Low-molecular-weight heparin (LMWH) has long been the cornerstone of treatment. Direct oral anticoagulants (DOACs) have shown comparable efficacy, and in some studies even potential advantages over LMWH. However, their safety varies across different tumor subtypes and anatomical sites. This finding suggests that bleeding risk and tumor-related factors should be incorporated into individualized decision-making. This article provides a systematic overview of the epidemiology and clinical burden of CAT, its mechanistic framework, diagnostic pathways, and treatment strategies, including prevention, therapy, duration of treatment, and follow-up. It also summarizes the major controversies in the current evidence base and outlines future research directions.