Management of cancer-associated thrombosis in patients with gastrointestinal cancers: lights and shadows.

Cancer-associated thrombosis (CAT) is a major cause of morbidity and mortality in patients with gastrointestinal (GI) malignancies and often negatively impact anti-cancer treatment delivery. A prothrombotic risk markedly varies across primary sites, from pancreatic, gastric to colorectal cancers and is influenced by tumor-driven inflammation, disease stage, and exposure to contemporary systemic therapies, including newly, immune checkpoint inhibitors, targeted agents, and antibody-drug conjugates. Despite its clinical relevance, current risk assessment models, including the pivotal Khorana score (KS), show limited accuracy in GI tumors and do not adequately account for treatment-related or biology-driven variability. This review synthesizes current evidence on the incidence, mechanisms, and clinical determinants of CAT in GI cancers and discusses approaches to primary thromboprophylaxis and secondary prevention, with attention to bleeding risk and cardiovascular considerations. Emerging strategies such as molecular profiling, inflammatory biomarkers, and ctDNA-based assessment of minimal residual disease (MRD) show promise for improving individualized risk prediction and guiding more precise anticoagulation strategies. A precision-medicine framework integrating tumor biology, dynamic biomarkers, and treatment-specific cardiovascular risk is needed to optimize CAT management and to inform future trials designed to refine primary and secondary prevention across the spectrum of GI malignancies.