Chemotherapy and thrombosis in gynecologic malignancy

Hypercoagulability State Combined with Post-Treatment Hypofibrinolysis in Invasive Breast Cancer: A Seven-Year Follow-Up Evaluating Disease-Free and Overall Survival

(1) Background: Cancer treatment, including chemotherapy, endocrine therapy, targeted therapy and radiotherapy, has been identified as an important independent risk factor for venous thromboembolism in cancer patients. The aim of the study was to evaluate the effect of adjuvant therapy on the coagulation and fibrinolysis components in invasive breast cancer. (2) Methods: Tissue factor pathway inhibitor (TFPI), tissue factor (TF), tissue plasminogen activator (t-PA), plasminogen activator inhibitor-1 (PAI-1) antigen (concentration) and TFPI and TF activities were examined in the blood samples of 60 breast cancer patients treated by adjuvant chemotherapy, endocrine therapy, radiotherapy and immunotherapy. Blood samples were taken 24 h before primary surgery and 8 months after tumour removal surgery. (3) Results: Adjuvant therapy administrated to breast cancer patients significantly increased the concentration of plasma TF, the PAI-1 antigen and also the activity of TFPI and TF, but significantly decreased the level of the t-PA antigen. Combined chemotherapy and endocrine therapy, but not monotherapy, has an important effect on haemostatic biomarker levels. (4) Conclusions: Breast cancer patients receiving adjuvant therapy have an elevated risk of developing a hypercoagulability and hypofibrinolysis state leading to venous thromboembolism.

Deep vein thrombosis and serum D-dimer after pelvic lymphadenectomy in gynecological cancer

INTRODUCTION

Venous thromboembolism prevention during the perioperative period requires comprehensive risk-level assessment. The aim of this study was to evaluate the incidence of deep vein thrombosis and to assess the cut-off levels of serum D-dimer as a screening strategy for deep vein thrombosis during the perioperative period.

METHODS

A total of 205 patients (ovarian cancer: 68, endometrial cancer: 76, cervical cancer: 61) who underwent gynecological surgery, including retroperitoneal lymph node dissection, were enrolled. We retrospectively analyzed the data on the cut-off value of D-dimer assessed using area under the receiver operating characteristic curve preoperatively, and 2 or 3 months, postoperatively. All patients underwent leg vein ultrasonography regardless of the serum D-dimer level. Furthermore, CT scans were performed to evaluate both disease status and venous thromboembolism, including pulmonary thromboembolism. Statistical analyzes were performed using the Mann-Whitney U-test (D-dimer values of each cancer), Chi-square test, Fisher's exact test (incidence of deep vein thrombosis), and one-way analysis of variance (patient characteristics).

RESULTS

A total of 205 patients (ovarian cancer: 68, endometrial cancer: 76, cervical cancer: 61) who underwent gynecological surgery, including retroperitoneal lymph node dissection, were included in the analysis. Deep vein thrombosis rates were significantly higher in patients with ovarian cancer (P<0.001). The postoperative D-dimer value was significantly higher than the preoperative value. Postoperative D-dimer values were also significantly higher in patients who received adjuvant chemotherapy (P=0.001). The cut-off value of D-dimer was 1.55 µg/mL preoperatively (sensitivity, 48.0%; specificity, 94.1%), and this value was higher postoperatively, at 1.95 µg/mL (sensitivity, 37.0%; specificity, 90.9%).

CONCLUSION

Postoperative D-dimer values are higher not only after surgery but also in patients who received adjuvant chemotherapy. The cut-off value of D-dimer at 2 or 3 months postoperatively was higher than preoperative value.

Venous thromboembolism in recurrent ovarian cancer-patients: A systematic evaluation of the North-Eastern German Society of Gynaecologic Oncology Ovarian Cancer Study Group (NOGGO)

INTRODUCTION

Systemic chemotherapy and surgery for patients with recurrent ovarian cancer (ROC) constitute a therapeutic challenge. Venous thromboembolism (VTE) seems to have a negative prognostic impact in patients with solid tumors including primary ovarian cancer in many series. Only limited contemporary data exist regarding the impact of VTE on ROC.

PATIENTS AND METHODS

Two large multicenter prospective controlled phase I/II-III studies on 2nd-line topotecan-based chemotherapy with platinum-sensitive or resistant ROC (N=525) were conducted on both operated and non-operative patients by the North-Eastern German Society of Gynaecologic Oncology Ovarian Cancer Study Group (NOGGO). Analysis was performed to identify incidence, predictors and prognosis of VTE. Survival analysis, univariate and Cox-regression analysis were performed to identify independent predictors of VTE, overall and progression free survival.

RESULTS

Thirty-seven (7%) VTE-episodes during chemotherapy were identified; 70% of them occurred within the first 2 months after initiation of chemotherapy. Ascites, as a sign of peritoneal carcinomatosis and advanced tumor disease, was identified as independent predictor of VTE. Advanced age and high BMI did not appear to affect significantly the VTE-incidence. High performance status, platinum-sensitivity, serous-papillary histology, lack of ascites and surgery appeared to positively affect survival by multivariate analysis. Overall survival and progression free survival were similar between the VTE and no-VTE patients.

CONCLUSION

ROC-patients appear to have the highest risk for developing VTE when ascites exists and during the first 2 months following chemotherapy initiation. In contrast to primary ovarian cancer, VTE could not be identified to affect overall survival in relapsed malignant ovarian disease.

Incidence of venous thromboembolism in patients with ovarian cancer undergoing platinum/paclitaxel-containing first-line chemotherapy: an exploratory analysis by the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group

PURPOSE

Venous thromboembolism (VTE) has been associated with negative prognosis in cancer patients. Most series reporting on VTE have included different tumor types not differentiating between recurrent or primary disease. Data regarding the actual impact of VTE on primary advanced ovarian cancer (AOC) are limited.

PATIENTS AND METHODS

Between 1995 and 2002, the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study group (AGO-OVAR) recruited 2,743 patients with AOC in three prospectively randomized trials on platinum paclitaxel-based chemotherapy after primary surgery. Pooled data analysis was performed to evaluate incidence, predictors, and prognostic impact of VTE in AOC. Survival curves were calculated for the VTE incidence. Univariate analysis and Cox regression analysis were performed to identify independent predictors of VTE and mortality.

RESULTS

Seventy-six VTE episodes were identified, which occurred during six to 11 cycles of adjuvant chemotherapy; 50% of them occurred within 2 months postoperatively. Multivariate analysis identified body mass index higher than 30 kg/m(2) and increasing age as independent predictors of VTE. International Federation of Gynecology and Obstetrics stage and surgical radicality did not affect incidence. Overall survival was significantly reduced in patients with VTE (median, 29.8 v 36.2 months; P = .03). Multivariate analysis identified pulmonary embolism (PE), but not deep vein thrombosis alone, to be of prognostic significance. In addition, VTE was not identified to significantly affect progression-free survival.

CONCLUSION

Patients with AOC have their highest VTE risk within the first 2 months after radical surgery. Only VTE complicated by symptomatic PE have been identified to have a negative impact on survival. Studies evaluating the role of prophylactic anticoagulation during this high risk postoperative period are warranted.

Defining practice patterns in Gynecologic Oncology to prevent pulmonary embolism and deep venous thrombosis

OBJECTIVE

The goal of venous thromboembolism (VTE) prophylaxis is to reduce the morbidity and mortality associated with the development of a deep venous thrombosis (DVT) or pulmonary embolism (PE). Because women with gynecologic cancers are at high risk to develop VTE, we sought to determine the present practice patterns of gynecologic oncologists regarding their use of VTE prophylaxis.

METHODS

1073 members of the Society of Gynecologic Oncologists (SGO) were mailed surveys that asked about preferred methods to prevent the development of VTE after gynecologic oncology surgery. Data were collected by online member entry and return mail. Frequency distributions were calculated and nonparametric test used for comparisons.

RESULTS

343/1073 (34%) of SGO members and fellows responded. 142/343 (42%) preferred double prophylaxis consisting of external pneumatic compression (EPC) and an anticoagulant while 41% (n=141) preferred EPC with no additional anticoagulation. Of respondents choosing any anticoagulant, 40% preferred Enoxaparin pre- and/or postoperatively. Ovarian cancer patients were perceived by respondents to have the highest risk of developing a postoperative PE.

CONCLUSIONS

Most respondents agree that women with gynecologic cancers undergoing major surgery should receive VTE prophylaxis, though there is not agreement as to which method is optimal. While 42% of members preferred double prophylaxis, 41% chose no additional measures other than EPC. Randomized studies in gynecologic oncology should be initiated in the United States to determine the optimal practice pattern.

Thromboembolic complications in patients with clear cell carcinoma of the ovary

OBJECTIVE

The purpose of this study was to define the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients with clear cell carcinoma (CCC) of the ovary and to investigate the prognostic factors in such patients.

METHODS

Between January 1987 and December 2003, 641 women with primary invasive epithelial ovarian cancer underwent treatment at the Royal Hospital for Women in Sydney, Australia. Sixty-six patients (10.3%) with CCC were identified from the data bank, and their data were compared with a matched-control group of 132 patients with non-clear cell epithelial ovarian carcinoma.

RESULTS

A thromboembolic event (DVT or PE) was noted in 27.3% of patients with CCC, compared to 6.8% of patients with other epithelial ovarian cancers. PE was detected in 13.6% and 3.8% of patients, respectively. In patients with CCC, DVT was frequently observed before operation or at the time of recurrence. In a multivariate analysis of patients matched for age and stage, the occurrence of a DVT or the presence of endometriosis was significant predictors of clear cell histology. Within the clear cell group, no particular risk factor for DVT could be identified. Metastases of 50 mm or greater in diameter, ascites of 1000 ml or more, advanced FIGO stage, and the occurrence of DVT were poor prognostic factors for CCC in univariate analysis, but in a multivariate Cox regression analysis, only FIGO stage and occurrence of DVT remained significant.

CONCLUSION

The incidence of venous thromboembolic events was found to be significantly higher in patients with CCC when compared to patients with other epithelial ovarian cancers.

Antithrombotic therapy in gynecologic surgery and gynecologic oncology

The European Consensus Conference has assessed the risk for thrombotic complications for most women undergoing gynecologic surgery and found it to be moderate. Nonetheless, it is important to analyze a patient's individual risk before surgery so that appropriate thrombosis prophylaxis can be given if increased risk is determined. Malignancy accounts for most thrombotic complications among gynecologic patients. Patients with known malignancies should receive prophylaxis during surgery, and some patients with breast cancer should receive prophylaxis during chemotherapy. Heparin, and low-molecular-weight heparin in particular, may favorably influence the outcome of cancer in some patients and treatment with these agents is currently under investigation in a number of trials as a new approach to anticancer therapy.