We thank Barcelóo et al. for their interest in our article.1 They suggest that baseline patient characteristics such as preexistent vascular disease, poor performance status, and erythropoietin use could provide additional information for calculating the risk of vascular events occurring during or after chemotherapy. However, screening for vascular disease (venous and arterial) through imaging studies such as Doppler ultrasound is hardly feasible, even in a prospective study. Rather, circulating markers of coagulation and inflammation can be associated with the risk of developing vascular events2 and should be the object of future research. Although more patients with vascular events had a baseline ECOG performance status of 2 compared with patients without vascular events (26.3% vs. 12.4%), this difference was not statistically significant and to our knowledge the role of performance status has not been supported in the published literature to date. However, one reasonable hypothesis is that single factors strictly involved in the determination of performance status such as pain, immobility, nutritional status, and disease extension could individually contribute to the risk of vascular events. Furthermore, the role of erythropoietin in vascular disease is acknowledged in the literature, but its role appears to be quantitatively modest.3 In our series, the use of this drug was found to be comparable between the two groups (20% vs. 22%).1

It is interesting to note that Barcelóo et al. emphasize the possible causative role of gemcitabine in the occurrence of arterial events. We reported seven cases of iliac artery embolism, all occurring in patients without a previous history of peripheral arterial disease. However, randomized trials comparing the gemcitabine–cisplatin doublet with other doublets do not to our knowledge support the finding of a higher incidence of arterial thrombosis.4 The underreporting of these adverse events could, in part, explain this finding.


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Gianmauro Numico M.D*, Marco Merlano M.D.*, Nicola Silvestris M.D.†, * Medical Oncology, S. Croce General Hospital, Cuneo, Italy, † Medical Oncology, S. Maria Goretti Hospital, Latina, Italy.