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Short Report
Risk of venous thrombosis in patients with hepatic malignancies undergoing surgical resection Todd J Yates, Marwan Abouljoud, Angela Lambing, Philip Kuriakose Department of Hematology and Oncology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, Michigan, USA, 48202 The risk of venous thrombosis is well documented in patients with malignancies, those undergoing abdominal surgery, and those undergoing hepatic resection for malignancy. This study was undertaken to determine whether there was a difference in the risk of thrombosis between those undergoing resection for hepatic metastases and primary hepatic malignancies. We performed a retrospective chart review of patients undergoing initial surgical resection for hepatic malignancies, primarily to determine whether there was a difference in the incidence of venous thrombosis between those with primary and secondary malignancies. Ninety-nine patients underwent surgical resection for either primary or secondary hepatic malignancies from 2001 to 2006. Seven of these patients, all with secondary hepatic malignancy, developed venous thrombosis within 3 months of resection. This retrospective review reveals that a clinical presentation of venous thrombosis is significantly more common among patients undergoing hepatic resection for secondary malignancy than those undergoing resection for primary cancer of the liver. Special attention with regard to prophylaxis for thrombosis may be required in these patients. Indian J Gastroenterol 2008 Jul-Aug; 27: 159-161.
T
he increased risk of thrombosis associated with either an abdominal surgery or the presence of a malignancy has been well documented in literature.1–5 The concurrent presence of these two factors appears to have an additive effect.6–8 However, it is not known whether the specific type of hepatic malignancy plays a role, or if prophylaxis for thrombosis can decrease this risk. We performed a retrospective review of records of patients who had undergone resection of hepatic neoplasm, to determine whether a correlation exists between venous thrombosis and type of tumor (primary versus metastatic).
Methods We performed a retrospective chart review of patients who had undergone resection for hepatic malignancy between 2001 and 2006, to evaluate whether they developed venous thrombosis within 3 months of surgery. All patients, except 3 who died of sepsis, were seen on followup. Patients were grouped according to whether their underlying malignancy was a primary hepatic neoplasm or metastases. Additional characteristics from these patients were also evaluated for any other confounding factors that may have played a role in the development of thrombosis. Data are expressed as mean (SD) values, and the student t-test, chi-square test or Fisher exact test were utilized to compare data between groups. A p value 0.99 1 15 69 3 3 1
(3.9) (4.2) (508.9)
2.9 (1.6) 15.2 (6.3) 967.0 (173.0)
0.08 0.29 0.11
(100%) (93.8%) (92.0%) (100%) (100%) (100%)
0 1 6 0 0 0
0.44
(0%) (6.3%) (8.0%) (0%) (0%) (0%)
68 (91.9%) 24 (96.0%)
6 (8.1%) 1 (4.0%)
0.68
1 (100%) 1 (100%) 90 (92.8%)
0 (0%) 0 (0%) 7 (7.2%)
>0.99
61 (89.7%) 7 (10.3%) 0.09 31 (100%) 0 (0%) only anticardiolipin antibodies and Factor V
Currently, there are no clear guidelines for thrombosis prophylaxis in patients with liver cancer. Patients who developed thrombosis in our study did receive prophylactic subcutaneous heparin throughout their hospitalization, in fact all 99 patients undergoing resection received prophylactic heparin; however, the dose of heparin and frequency of dosing were not consistent. On discharge, no further therapy was given. The literature provides evidence in support of extending the period of prophylaxis, as it has been shown that this reduces the incidence of venous thrombosis.6 Patients undergoing surgical resection for secondary malignancy may be more prone to thromboses. There is approximately a 10% increased risk of developing thrombosis among patients undergoing resection of liver metastases. This is in conformity with other studies that have shown the development of thrombosis to be greatly increased in the setting of metastasis.10,11,12 The risk of developing thrombosis in the setting of a primary liver
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Yates, Abouljoud, Lambing, et al
Venous thrombosis after surgery for hepatic malignancies
malignancy is only about 1.8%.13 It must be emphasized that venous thrombosis was diagnosed based on clinical presentation and confirmed by investigation, but was not looked for actively by the protocol in all patients. Therefore, the true incidence of venous thrombosis in these patients may be much higher than described. Clinicians need to be aware of the risk of thrombosis in the setting of surgery for metastatic liver tumors. Further studies are required to confirm this postulate and to better define the length of time that thrombosis prophylaxis should be continued to prevent these events in this high-risk patient population.
References
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Bergqvist D, Agnelli G, Cohen AT, Eldor A, Nilsson PE, Le Moigne-Amrani A, et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med 2002;346:975–80.
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Flordal PA, Bergqvist D, Burmark U-S, Ljungstrom KG, Torngren S. Major thromboembolism and diffuse bleeding after elective general abdominal surgery—clinical risk factors. Thromb Hemost 1995;73:1096 [Abstract].
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Kakkar AK, Williamson RC. Prevention of venous thromboembolism in cancer patients. Sem Thromb Hemost 1999;25:239– 43.
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Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Anderson FA Jr, et al. Prevention of venous thromboembolism. Chest 2001;119:132S–175S.
10. Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Malignancies, prothrombotic mutations and the risk of venous thrombosis. JAMA 2005;293:715–22.
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Heit JA, O’Fallon WM, Petterson TM, Lohse CM, Silverstein MD, Mohr DN, et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med 2002;162:1245–8.
11. Francis JL, Biggerstaff J, Amirkhosravi A. Hemostasis and malignancy. Sem Thromb Hemost 1998;24:93–109.
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Khushal A, Quinlan D, Alikhan R, Gardner J, Bailey C, Cohen A. Thromboembolic disease in surgery for malignancy—rationale for prolonged thromboprophylaxis. Semin Thromb Hemost 2002;28:569–76.
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Donati MB. Cancer and thrombosis. Hemostasis 1994;24:128– 31.
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Ambrus JL, Ambrus CM, Pickern J, Soldes S, Bross I. Hematologic changes and thromboembolic complications in neoplastic disease and their relationship to metastasis. J Med 1975;6:433– 58.
12. Sallah S, Wan JY, Nguyen NP. Venous thrombosis in patients with solid tumors: determination of frequency and characteristics. Thromb Hemost 2002;87:575–9. 13. Stein PD, Beemath A, Meyers FA, Skaf E, Sanchez J, Olson RE. Incidence of venous thromboembolism in patients hospitalized with cancer. Am J Med 2006;119:60–8. Correspondence to: Dr. Yates, Department of Hematology/Oncology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202; Tel: 313-916-9052; Fax: 313-916-7911 E-mail:
[email protected] Received March 20, 2008. Received in final revised form May 7, 2008. Accepted June 27, 2008
News and Notices
Medical College, Ludhiana 141008. E-mail:
[email protected]
Medical Education Fellowships-2009: CMCLFAIMER Regional Institute, Christian Medical College, Ludhiana
A conference on “Inflammatory Bowel Disease: ProblemOriented Approach” will be held at the P D Hinduja National Hospital, Mumbai 400 016, November 8 and 9, 2008.
The CMCL-FAIMER regional Institute’s Fellowship is a two-year fellowship program designed for Indian medical school faculties who have the potential to play a key role in improving medical education at their institutes. The program is uniquely designed to teach education methods and leadership skills, as well as to develop strong professional bonds with other medical educators. The fellowship is now running in its fourth year. Sixteen fellowships are on offer for the year 2009. Requirements for selection are submission of a curriculum innovation project proposal and letter of support from applicant’s institute. Limited funding is available to support fellows’ travel, local expenses and course fee. Applications open from: July 1 to October 15, 2008 The application process is online at https://faimeronline2.ecfmg.org/ For details, please visit http://cmcl.faimer.googlepages.com/home For details, contact: Prof. Tejinder Singh, Program Director, Christian
For details, contact: Dr Devendra Desai, Room 1106, Clinic Building, P D Hinduja National Hospital, Mahim, Mumbai 400 016. Fax: (22) 2444 0425. E-mail:
[email protected] A Workshop on Clinical Research Methodology will be held in Lucknow on 10-12 December, 2008, under the aegis of the U.S. National Institutes of Health and the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow. Applicants should email a short (strictly in one page) summary of their experience, expertise and current activities in clinical research by October 31, 2008 to Paolo Miotti, U.S. Embassy, New Delhi (
[email protected]). A selection committee will notify the successful applicants of their acceptance. Participants’ travel and hotel expenses will be covered by the workshop organizers.
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