Perioperative coagulopathy in patients undergoing primary cytoreduction

Vascular endothelial growth factor staining and elevated INR in advanced epithelial ovarian carcinoma

BACKGROUND

The purpose of this study was to determine whether vascular endothelial growth factor (VEGF) expression in tumors correlates with the incidence of an elevated prothrombin time (PT), specifically an international normalized ratio (INR) > or = 1.4, in patients undergoing primary surgical cytoreduction for ovarian cancer.

METHODS

INRs were obtained on all patients perioperatively. VEGF expression was determined by immunostaining of tumor specimens using published protocols.

RESULTS

One hundred patients underwent surgical cytoreduction. Sixty-seven percent of patients had postoperative INR of 1.4 or greater. INRs of greater than or equal to 1.8 were found in 5% of patients. INR elevation was independent of mean estimated blood loss (EBL) with the EBL in the patients with INRs > or = 1.4 not significantly different than the EBL in the patients with INRs < 1.4 (660 ml vs. 530 ml, P = 0.09). There was a significant correlation between elevated INR and tumor VEGF immunostaining (P < 0.005). All but one patient with an elevated INR had positive VEGF staining.

CONCLUSIONS

In conclusion, development of an elevated INR (INR > or = 1.4) is common in patients undergoing primary surgical cytoreduction. Positive tumor VEGF staining is very common in patients having a postoperative coagulopathy.

Prognostic significance of tumor necrosis in ovarian cancer patients treated with neoadjuvant chemotherapy and interval surgical debulking

The objective of this study was to study the significance of tumor necrosis documented at the time of interval surgical debulking after neoadjuvant chemotherapy. Retrospective chart reviews were carried out from 1997 to 2005 to identify ovarian cancer patients treated with neoadjuvant chemotherapy. Patients' demographics together with disease characteristics, treatment-related variables, and outcomes were recorded. Cox proportional hazard models were built to model time to progression using predictor variables such as age, cancer stage, tumor grade, residual disease, percentage change in CA125 level from baseline, and degree of necrosis in resected tumor specimens. One hundred one patients were included in the study. Optimal debulking was achieved in 74% of the patients. Cox regressions revealed three significant predictive variables of time to first progression: younger age (hazard ratio [HR] = 0.95, 95% CI 0.92-0.98, P= 0.004), residual disease (P= 0.048), and the absence/minimal tumor necrosis after three cycles of neoadjuvant chemotherapy (HR = 1.97, 95% CI 1.01-3.87, P= 0.048). The estimated median survival was 50.66 months (95% CI 46.12-55.20). The lack of or minimal tumor necrosis after neoadjuvant chemotherapy is an independent risk factor for recurrent disease.

Prognostic Significance of Postoperative Morbidities in Patients With Advanced Epithelial Ovarian Cancer Treated With Neoadjuvant Chemotherapy and Delayed Primary Surgical Debulking

BACKGROUND

To examine the prognostic significance of postoperative morbidities in patients with ovarian cancer treated with neoadjuvant chemotherapy and interval surgical debulking.

METHODS

Retrospective chart reviews of all patients treated with neoadjuvant chemotherapy and interval debulking were performed from 1999 to 2002. Descriptive statistics were used to summarize the distributions of important clinical variables. Logistic regression was used to identify statistically significant predictors of postoperative morbidities. Cox regression was used to model time to first clinical progression. Survivals were estimated by the Kaplan-Meier method and compared with the log rank test. P < .05 was considered to be statistically significant.

RESULTS

Fifty-eight patients were treated with neoadjuvant platinum-taxane combination chemotherapy. Major surgical complications were observed in four patients (6.8%). There were no perioperative deaths. The presence of concurrent medical comorbidities was associated with the development of significant postoperative morbidities (P = .038). Cox regression showed any macroscopic residual disease (P = .04) and the presence of significant postoperative morbidities (odds ratio, 4.7, 95% confidence interval, 1.8-12.7, P = .002) to be predictive of a shorter progression-free interval.

CONCLUSIONS

Neoadjuvant chemotherapy followed by interval surgical debulking carried a low risk for postoperative morbidity. The adverse influence of marked postoperative morbidity on progression-free survival needs further study.

Transfusion utilization during adnexal or peritoneal cancer surgery: Effects on symptomatic venous thromboembolism and survival

OBJECTIVE

To determine whether perioperative packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions during ovarian, tubal, or peritoneal cancer surgery increase the risk of symptomatic postoperative venous thromboembolism (VTE) and adversely affect overall survival.

METHODS

We conducted a retrospective review of all cases of surgical exploration for resection of stage IIIC-IV adnexal/peritoneal cancer between November 1998 and May 2002 at Memorial Sloan-Kettering Cancer Center. Patients with a history of prior or active preoperative VTE were excluded. Routine intraoperative and postoperative VTE prophylaxis including lower extremity external pneumatic compression with or without postoperative subcutaneous heparin was utilized in all cases. Symptomatic postoperative VTE was diagnosed by lower extremity Doppler or computerized tomography (excluding cases with only ovarian vein thrombosis). Clinical parameters were examined by a logistic regression analysis to identify independent prognostic predictors of postoperative symptomatic VTE, which occurred within 30 days of surgery. Survival was calculated using the Kaplan-Meier method.

RESULTS

In all, 174 patients underwent exploratory surgery, and 6 (3.4%) were excluded due to active or prior history of VTE. Of the remaining 168 patients, 71 (42%) received at least one perioperative transfusion of PRBC or FFP. Postoperative VTE was documented in 5 of 46 (11%) patients who received a postoperative transfusion compared to 3 of 122 (2.5%) patients who did not (P = 0.04; odds ratio, 4.8); moreover, VTE was noted in 3:16 (19%) patients who received postoperative FFP compared to 5:152 (3.3%) patients who did not (P = 0.01, odds ratio of 6.78). Age, stage, body mass index, length of the operation, blood loss, presence of ascites, volume of ascites, residual disease status, preoperative hemoglobin level and coagulation profile were not associated with increased risk for VTE. When survival results were stratified by transfusion utilization and controlling for optimal debulking status, perioperative transfusions had no apparent effect on overall survival.

CONCLUSION

In women with stage IIIC-V disease, postoperative blood product transfusions particularly FFP were associated with increased risk of DVT and PE, but transfusions had no impact on overall survival.

Recurrent ovarian carcinoma: is there a place for surgery?

The role of cytoreductive surgery is well established in patients with primary ovarian carcinoma. Minimal residual disease translates to improved response to adjuvant treatment and prolonged survival. For close clinical follow-up, different approaches may be helpful in detecting recurrent disease, including regular physical/pelvic examination, serial CA-125 levels, and imaging studies using computerized tomography, magnetic resonance imaging, or positron emission testing. At recurrence, those patients with a good performance status, a good response to primary therapy, and a macronodular tumor distribution pattern may be candidates for a secondary cytoreductive procedure. Data suggests that secondary cytoreduction is superior to chemotherapy alone in patients who have a significant disease-free interval (6 to 12 months). Survival after secondary cytoreduction is optimized with cytoreduction to microscopic disease, yet there is a recognized risk of surgical morbidity. Therefore, a strong relationship between the gynecologic oncology surgeon and the patient is key to obtaining appropriate informed consent and relaying appropriate outcome expectations.

Hemostatic changes in patients with brain tumors

Abnormal hemostasis is a functional property of cancer. Hemostatic abnormalities are common in patients with systemic malignant disease and brain tumors. However, the incidence of thromboembolism is higher in patients with brain tumors than in those with systemic disease. This raises the question of whether or not hemostatic abnormalities found in the blood of the two groups of patients differs, suggesting different pathogeneses. The purpose of this report is to review abnormalities in blood and clinical manifestations of abnormal hemostasis found in brain tumors and cancer patients in an attempt to answer this question. Normal hemostasis, as currently understood, will be considered with an emphasis on features unique to the central nervous system.