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\begin{document}

\title{Prolonged Prothrombin Time Does Not Correlate with Clinical Bleeding
Symptoms in Newly Diagnosed Pediatric Leukemia Patients}



\author[1]{Maha Al-Ghafry}%
\author[1]{Abraham Haimed}%
\author[2]{Julia Su}%
\author[3]{Suchitra Acharya }%
\affil[1]{Steven and Alexandra Cohen Children's Medical Center}%
\affil[2]{Donald and Barbara Zucker School of Medicine at Hofstra/Northwell}%
\affil[3]{Long Island Jewish Medical Center}%


\vspace{-1em}



  
  \date{May 28, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Prolonged prothrombin time (PT) and/or activated partial thromboplastin
time (aPTT) are frequently seen in newly diagnosed pediatric leukemia
patients (NDPLP), which can lead to delayed diagnostic and therapeutic
procedures due to concern for bleeding. In this single center
retrospective study of NDPLP we analyzed these parameters in 93 patients
(aged 1-21 years). None had a personal history of bleeding, but 33.3\%
had bleeding symptoms within 30 days of presentation, predominantly
mucosal bleeding (80.6\%) and petechiae (64.5\%). Median laboratory
values at diagnosis: white blood cell count 15.7, hemoglobin 8.1,
platelets 64, PT 13.2, and a PTT 31. Red blood cells were administered
in 41.2\%, platelets in 52.9\%, FFP in 7.8\%, and vitamin K in 21.6\%
based on institutional cut-off values for replacement or clinical
symptoms. Prolonged PT was found in 54.8\% of patients (factor VII
33.1\% (interquartile range {[}IQR{]} 19.4-50.5), while aPTT was
prolonged in 5.4\%. Anemia and thrombocytopenia did not correlate with
prolonged PT (p=0.73 and p=0.18 respectively), or prolonged aPTT (p=0.52
and 0.42). Leukocytosis and neutrophilia showed significant correlation
with elevated PT (p\textless{}0.001 and \textless{}0.01 respectively),
but not aPTT (p=0.3 and 0.5). Bleeding symptoms upon presentation did
not correlate with prolonged PT (p=0.83), prolonged aPTT (p=1) or anemia
(p=0.06) but had significant correlation with thrombocytopenia
(p=\textless{}0.0001) and elevated AST (p=0.05). Therefore, a prolonged
PT in NDPLP may not necessitate the reflexive use of blood product
replacement in the absence of significant bleeding, which is likely
related to leukocytosis than to a true coagulopathy.%
\end{abstract}%



\sloppy


\emph{Title:} \emph{Prolonged Prothrombin Time Does Not Correlate with
Clinical Bleeding Symptoms in Newly Diagnosed Pediatric Leukemia
Patients}

\emph{Submission to:} Pediatric Blood and Cancer

\emph{Authors:}

Al-Ghafry, Maha\textsuperscript{1,3}; Haimed,
Abraham\textsuperscript{2,3}; Su, Julia\textsuperscript{3}; and Acharya,
Suchitra S\textsuperscript{1,3}.

\begin{enumerate}
\tightlist
\item
  Division of Pediatric Hematology, Oncology and Stem Cell Transplant -
  Cohen Children's Medical Center, New Hyde Park, New York
\item
  Department of Pediatrics - Cohen Children's Medical Center, New Hyde
  Park, New York
\item
  Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
\end{enumerate}

\emph{Corresponding Author:}

Suchitra Acharya, MD

Cohen Children's Medical Center,

269-01 76\textsuperscript{th} Avenue, Suite 255, New Hyde Park, NY,
11040

Email: sacharya@northwell.edu

Phone: (718) 470-3460

Fax: (718) 343-4642

\emph{Additional Information:}

Main text word count: 1448

Abstract word count: 244

Tables: 2

Figures: 1

Supporting files: 0

Short running title: PT does not correlate with bleeding in new leukemia

Keywords: Leukemia, Coagulation, Hemorrhage, Bleeding, Prothrombin Time,
Transfusion

\emph{Abbreviations}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Abbreviation} & \textbf{Full text}\tabularnewline
\midrule
\endhead
ALL & Acute lymphoblastic leukemia\tabularnewline
AML & Acute myeloid leukemia\tabularnewline
APL & Acute promyelocytic leukemia\tabularnewline
aPTT & activated partial thromboplastin time\tabularnewline
CVL & central venous line\tabularnewline
FFP & fresh frozen plasma\tabularnewline
Pre-B ALL & pre-B cell acute lymphoblastic leukemia\tabularnewline
PT & prothrombin time\tabularnewline
RBCs & Red blood cells\tabularnewline
T-ALL & T-cell acute lymphoblastic leukemia\tabularnewline
\bottomrule
\end{longtable}

\emph{Abstract}

Prolonged prothrombin time (PT) and/or activated partial thromboplastin
time (aPTT) are frequently seen in newly diagnosed pediatric leukemia
patients (NDPLP), which can lead to delayed diagnostic and therapeutic
procedures due to concern for bleeding. In this single center
retrospective study of NDPLP we analyzed these parameters in 93 patients
(aged 1-21 years). None had a personal history of bleeding, but 33.3\%
had bleeding symptoms within 30 days of presentation, predominantly
mucosal bleeding (80.6\%) and petechiae (64.5\%). Median laboratory
values at diagnosis: white blood cell count 15.7, hemoglobin 8.1,
platelets 64, PT 13.2, and a PTT 31. Red blood cells were administered
in 41.2\%, platelets in 52.9\%, FFP in 7.8\%, and vitamin K in 21.6\%
based on institutional cut-off values for replacement or clinical
symptoms.

Prolonged PT was found in 54.8\% of patients (factor VII 33.1\%
(interquartile range {[}IQR{]} 19.4-50.5), while aPTT was prolonged in
5.4\%.

Anemia and thrombocytopenia did not correlate with prolonged PT (p=0.73
and p=0.18 respectively), or prolonged aPTT (p=0.52 and 0.42).
Leukocytosis and neutrophilia showed significant correlation with
elevated PT (p\textless{}0.001 and \textless{}0.01 respectively), but
not aPTT (p=0.3 and 0.5). Bleeding symptoms upon presentation did not
correlate with prolonged PT (p=0.83), prolonged aPTT (p=1) or anemia
(p=0.06) but had significant correlation with thrombocytopenia
(p=\textless{}0.0001) and elevated AST (p=0.05). Therefore, a prolonged
PT in NDPLP may not necessitate the reflexive use of blood product
replacement in the absence of significant bleeding, which is likely
related to leukocytosis than to a true coagulopathy.

\emph{Introduction}

Acute leukemia in pediatric patients can present with bleeding symptoms
such as bruising, petechiae and epistaxis secondary to thrombocytopenia,
endothelial cell injury, abnormal fibrinolysis, disseminated
intravascular coagulation (DIC), or inherited bleeding disorders such as
von Willebrand disease or clotting factor deficiencies(1). Bleeding,
along with thrombosis, in acute promyelocytic leukemia (APL) has been
attributed to augmented fibrinolysis via increased expression of tissue
plasminogen activator (tPA) and urokinase-type plasminogen activator
(uPA), leading to generation of plasmin and degradation of fibrin(2).
Enhanced fibrinolysis, in addition to thrombocytopenia and DIC, leads to
the bleeding diathesis seen in these patients.

Abnormal coagulation screening in pediatric patients diagnosed with
leukemia include prolonged prothrombin time (PT) and/or activated
partial thromboplastin time (aPTT), which are common at presentation.
These abnormalities generally require further work up due to the need
for rapid diagnostic procedures (such as a lumbar puncture and bone
marrow aspirate and/or biopsy), along with central venous line (CVL)
placement for initiation of chemotherapy. Abnormal coagulation screening
tests requiring further work up can lead to delays in procedures due to
concerns of bleeding. There is also a tendency to achieve correction of
the PT/aPTT using fresh frozen plasma (FFP) and/or vitamin K, in the
hope of preventing bleeding during the procedure, which is not
evidence-based.

A systematic review by Liontos et al(3) did not find evidence of utility
of routine pre-operative coagulation testing to predict perioperative
bleeding with different types of procedures. However, given the complex
interplay of factors involved in the leukemia population, it is unclear
if abnormal screening coagulation tests, in the absence of significant
bleeding, increase bleeding risk. Even more unclear is the utility of
correcting these abnormal values using blood products to prevent
peri-procedural bleeding. Therefore, the aim of this study was to assess
if there was a correlation between prolonged PT/aPTT and bleeding
symptoms or other laboratory parameters measured at initial leukemia
diagnosis, with the goal of reassessing the need for work up of these
abnormal results to justify use of blood products to correct laboratory
values.

\emph{Methods}

This single-center retrospective study of newly diagnosed pediatric
leukemia patients, 1 to 21 years of age, was conducted at Cohen
Children's Medical Center (New York) from January 2015 to December 2018,
after appropriate institutional ethics approval. Inclusion criteria
were: new diagnosis of leukemia including pre-B cell acute lymphoblastic
leukemia (pre-B ALL), T-cell acute lymphoblastic leukemia (T-ALL), acute
myelogenous leukemia (AML), acute promyelocytic leukemia (APL), mature B
cell leukemia or biphenotypic leukemia. Exclusion criteria included:
prior leukemia diagnosis, leukemia relapse, chemotherapy for leukemia at
an outside institution, treatment with steroids within the month prior
to presentation, previously diagnosed congenital or acquired
coagulopathy (in addition to known or suspected renal or hepatic
disease) and transfer to outside institution prior to undergoing
procedures. Patients' relevant history, presenting symptoms (including
bleeding/clotting), diagnosis and laboratory values were extracted.
Exact Wilcoxon tests and Fisher's Exact tests were performed, as
appropriate, to compare lab values and bleeding symptoms with PT and
aPTT.

\emph{Results}

Ninety-three patients met inclusion criteria out of 144 records reviewed
during the study period. Patients were 43\% female, of varied races,
21.5\% had a medical history (e.g. asthma), none with a personal history
of bleeding and one patient had a family member with documented bleeding
history (menorrhagia) -- Table 1. A third of patients had bleeding
symptoms upon presentation, which were most commonly bruising (80.6\%)
and petechiae (64.5\%).

Patients were diagnosed (via peripheral blood flow and/or bone marrow
studies) predominantly with ALL (82.7\%). Of these, 82.9\% had pre-B
cell ALL and 17.1\% had T-cell ALL. The remainder of diagnoses were AML
(12.9\%), APML (3.2\%), biphenotypic leukemia (2.2\%), and mature B cell
leukemia (2.2\%). All patients underwent a lumbar puncture (LP), bone
marrow aspirate (and bone marrow biopsy for some patients) along with
CVL placement for chemotherapy. One patient was diagnosed via fluid from
a pleural effusion.

Two patients had minor bleeding (both WHO grade 2) noted at a procedure
site. One patient had a bleed at the LP site (day 2 post-procedure),
with normal PT/aPTT at presentation; bleeding was attributed to
thrombocytopenia which resolved with a pressure bandage. The second
patient had bleeding at the CVL site (day 1 post-procedure) and had
presented with a PT of 13.9. This was not corrected initially, but
patient was initiated on a course of vitamin K for the CVL site bleed.

Laboratory data are also presented in Table 1. The median age at
diagnosis was 8 years (interquartile range {[}IQR{]} 3-12) with
hematologic lab values as follows: white blood cell count (WBC) with
leukocytosis (median 15.7; IQR 5.3-57.2), anemia with hemoglobin 8.1
(5.7-10.4), thrombocytopenia with platelets 64 (24-119), mildly
prolonged prothrombin time (PT) at 13.2 (12.4-15.4), and normal partial
thromboplastin time at 31 (27.4-33.6). Fibrinogen (343; 227-465) and
D-dimer (834; 341-2869) were obtained in 37.6\% and 22.5\% of patients
respectively, which were both elevated. Chemistries were obtained, most
notably with an elevated LDH (637; 368-1218).

Prolonged PT was found in over half of patients (N=51, 54.8\%) and only
5 had prolonged aPTT (5.4\%). Of interest, 84.6\% (11 of 13) patients
with T cell leukemia had prolonged PT, along with 58.3\% of patients
with AML, and all 3 patients with APML. In our cohort, less than 27\% of
patients with prolonged PT/aPTT had factor levels obtained; of those,
factor VII had the lowest activity with a median of 33.1\% (19.4-50.5).

Varying blood products were administered for prophylaxis per institution
guidelines prior to procedures (for hemoglobin \textless{}8 g/dL,
platelets \textless{}10 K/uL, PT \textgreater{}15 s). Red blood cells
(RBCs) were administered in 41.2\% of patients, platelets in 52.9\%, FFP
in 7.8\% and vitamin K in 21.6\%.

Anemia and thrombocytopenia did not appear to correlate with prolonged
PT (p=0.73 and p=0.18 respectively), nor with prolonged aPTT (p=0.52 and
0.42 respectively). Leukocytosis, however, showed significant
correlation with elevated PT (p\textless{}0.001), but not aPTT (p=0.3)
-- Figure 1. This was also seen with elevated absolute neutrophil count
with elevated PT (p\textless{}0.01), but not aPTT (p=0.5). Bleeding
symptoms did not correlate with prolonged PT (p=0.83), prolonged aPTT
(p=1) or anemia (p=0.06), but had significant correlation with
thrombocytopenia (p=\textless{}0.0001) and elevated AST (p=0.05).

\emph{Discussion}

In our cohort of newly diagnosed pediatric leukemia patients, a third
presented with bleeding symptoms, which correlated significantly with
thrombocytopenia, but not with prolonged PT or aPTT. Interestingly, over
half of patients presenting with a prolonged PT had significant
correlation with leukocytosis. All patients with APL presented with
elevated PT (which is consistent with published literature(4), along
with most patients with T-cell ALL, which has been reported in adult
T-cell patients(5).

The leukemic process can lead to the unregulated production of white
blood cells with increased inflammation by release of cytokines and
stress hormones(6). Hepatic dysfunction can also occur due to leukemic
infiltration (as noted by increased bleeding symptoms correlating with
elevated AST upon presentation), leading to deficiencies in coagulation
factors synthesized by the liver. Factor VII was most notably affected
due to its short half-life(7), contributing to a prolonged PT. However,
bleeding in newly diagnosed leukemia patients is most likely related to
thrombocytopenia as noted in our study, and not a prolonged PT.
Thrombocytopenia is common in hematologic malignancies(8), with a
platelet count below 10 K/uL leading to increased risk of hemorrhage(9).

Use of products such as FFP and vitamin-K prior to procedures in those
with a prolonged PT is routinely practiced. With the finding of low
factor VII levels in pediatric leukemia patients upon initial
presentation, the use of targeted therapy with factor VII concentrate
may be appropriate for major procedures such as lumbar punctures, to
avoid administration of FFP with its complications such as fluid
overload and allergic reactions. In inherited FVII deficiency,
significant bleeding occurs with levels \textless{}10\%, and whether
this can be applied to acquired FVII deficiency is debated. Furthermore,
the automated use of product replacement may not be indicated in the
absence of significant bleeding associated with a prolonged PT and low
FVII levels, which are likely related to leukocytosis than to a true
coagulopathy. A previous study from our institution observed that low
FVII levels do not predict peri-op bleeding even in the absence of
intervention(10). In an adult study by Benlakhal et al(11), they
recommended a FVII cut off of 10\% in considering replacement therapy,
irrespective of bleeding phenotype, for major surgeries (sensitivity of
87\% and negative predictive value of 94\% for 7\% cutoff).

The limitations to this study are its retrospective design (with
reliance on documentation for patient history) and incomplete patient
workup in relation to abnormal laboratory values (such as prolonged PT
and factor deficiencies). Nonetheless, the findings in our patients may
enable tailoring the use of blood products based on significant bleeding
symptoms and avoiding treating abnormal values in the absence of
clinical bleeding.

\emph{REFERENCES}

1. Kwaan HC, Huyck T. Thromboembolic and bleeding complications in acute
leukemia. Expert Rev Hematol. 2010;3(6):719-30.

2. Kwaan H. D\emph{ouble Hazard of Thrombophilia and Bleeding}

\emph{in Leukemia} . American Society of Hematology Education Program:
Hematology; 2007. p. 151-7.

3. Liontos L, Fralick M, Longmore A, Hicks LK, Sholzberg M. Bleeding
Risk Using INR/aPTT Pre-Surgery: Systemtic Review (BRUISR). Blood2017.

4. Breen KA, Grimwade D, Hunt BJ. The pathogenesis and management of the
coagulopathy of acute promyelocytic leukaemia. Br J Haematol.
2012;156(1):24-36.

5. Li XY, Zhou YL, Zhang Y, Huang X, Li JH, Wang HP, et al. Coagulation
profile in newly diagnosed T-cell acute lymphoblastic leukemia. Thromb
Res. 2021;203:69-71.

6. Dhabhar FS, Miller AH, McEwen BS, Spencer RL. Stress-induced changes
in blood leukocyte distribution. Role of adrenal steroid hormones. J
Immunol. 1996;157(4):1638-44.

7. da Silva VA, Silva SS, Martins FF. Acquired deficiency of coagulation
factor VII. Rev Bras Hematol Hemoter. 2015;37(4):269-71.

8. Shaw JL, Nielson CM, Park JK, Marongiu A, Soff GA. The incidence of
thrombocytopenia in adult patients receiving chemotherapy for solid
tumors or hematologic malignancies. Eur J Haematol. 2021;106(5):662-72.

9. Wandt H, Schaefer-Eckart K, Wendelin K, Pilz B, Wilhelm M, Thalheimer
M, et al. Therapeutic platelet transfusion versus routine prophylactic
transfusion in patients with haematological malignancies: an open-label,
multicentre, randomised study. Lancet. 2012;380(9850):1309-16.

10. Badawi MH, Lieb KT, Fishbein J, Acharya SS. Pediatric Bleeding
Questionnaire as a predictor of perioperative bleeding in patients~with
low factor VII levels. Pediatric Hematology Oncology Journal2021. p.
37-41.

11. Benlakhal F, Mura T, Schved JF, Giansily-Blaizot M, Deficiency
FSGoFV. A retrospective analysis of 157 surgical procedures performed
without replacement therapy in 83 unrelated factor VII-deficient
patients. J Thromb Haemost. 2011;9(6):1149-56.

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