What is the optimal venous thromboembolism prophylaxis for gynecological oncology patients with CNS metastases?
► CNS metastases of gynecologic cancers will be seen more frequently in the future. ► Chemical thromboprophylaxis carries perioperative risk for neurosurgical procedures. ► Peer-reviewed literature has not addressed the risks and benefits of thromboprophylaxis in gynecologic metastases to the CNS.
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ABSTRACT: To evaluate a quality improvement protocol for venous thromboembolism prevention in postoperative gynecologic cancer patients. On January 1, 2006, we initiated a universal protocol of dual prophylaxis with sequential compression devices and three times daily heparin (or daily low molecular weight heparin) until discharge in gynecologic cancer patients having major surgery. Patients with both malignancy and age over 60 years (or history of prior clot) were discharged on 2 weeks of anticoagulant. Before January 2006, all patients were given sequential compression devices starting before the induction of anesthesia, continuing until discharge from the hospital. Records of gynecologic cancer service patients admitted in 2005 and 2006 were reviewed, excluding patients with a history of heparin-induced thrombocytopenia or those admitted on an anticoagulant. Any pulmonary embolism or deep vein thrombosis diagnosed within 6 weeks of surgery was identified. We performed chi2 and Wilcoxon rank sum tests as well as multivariable regression analysis for confounders. Six of the 311 women meeting inclusion criteria in 2006 (1.9%) and 19 of 294 (6.5%) in 2005 had venous thromboembolism (odds ratio 0.33, 95% confidence interval 0.12-0.88, multivariable analysis adjusting for baseline differences between the groups). Heparin was given to 98.1% of patients in the hospital in 2006, and 91.1% of those meeting high-risk criteria were discharged on an anticoagulant. No differences in major bleeding complications were seen between years. A protocol of dual prophylaxis with prolonged prophylaxis in high-risk patients was successfully implemented and was associated with a significant reduction in the rate of venous thromboembolism without increasing bleeding complications. II.Obstetrics and Gynecology 12/2008; 112(5):1091-7. DOI:10.1097/AOG.0b013e31818b1486 · 4.37 Impact Factor
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ABSTRACT: Ovarian cancer is the leading cause of death in women with gynecological malignancies. Brain metastases are considered an uncommon metastatic site. Only few data exist on prognostic factors for this patient collective. A multicenter retrospective chart review was carried out including all patients with histologically confirmed ovarian cancer from six different German hospitals from 1981 to 2008. Overall, 4277 cases of patients with ovarian cancer were screened and patients with brain metastasis were identified and analyzed regarding various clinical variables and survival. A total of 74 women with brain metastases were identified, resulting in an incidence of 1.73%. In multivariate analysis, the following clinical parameters had a significant impact on overall survival: multiple lesions [hazard ratio (HR) 4.4, 95% confidence interval (CI) 2.0-9.7] and low grading (HR 3.1, 95% CI 1.7-5.8) were associated with a negative impact. Platinum sensitivity (HR 0.23, 95% CI 0.12-0.48) was significantly associated with a favorable outcome. Good performance status (60%-80% HR 0.48, 95% CI 0.23-0.99 and 90%-100% HR 0.21, 95% CI 0.08-0.53) also had a positive impact on overall survival. Platinum sensitivity is the most important prognostic factor in patients with ovarian cancer metastatic to the brain. This novel finding should be considered in the strategy of multimodal therapy for brain metastases in ovarian cancer.Annals of Oncology 05/2010; 21(11):2201-5. DOI:10.1093/annonc/mdq229 · 6.58 Impact Factor
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ABSTRACT: Prophylactic therapies have demonstrated efficacy in reducing the incidence of deep venous thrombosis (DVT) in neurosurgical patients. Retrospective analysis of patients undergoing neurosurgical procedures at the University of Michigan demonstrated a high incidence (14%) of postoperative DVT among patients with intracranial neoplasms treated with sequential compression device (SCD) prophylaxis alone. Therefore, we investigated the efficacy and safety of the low-molecular weight heparin enoxaparin in preventing DVT in patients with brain tumors. The goal of the study was to compare SCD, enoxaparin, and combined SCD/enoxaparin prophylaxis among patients requiring surgery for treatment of intracranial neoplasms. Eligible patients were randomized to SCD, enoxaparin, or combined therapy. Treatment was initiated before the induction of anesthesia and was continued throughout the hospital stay. Patients were screened for DVT, using duplex imaging, on four occasions in the first 1 month after surgery. The incidences of DVT and serious adverse events were compared between groups using analysis of variance and the Dunnet two-sided t test. Sixty-eight patients completed the study. Postoperative DVT occurred in 3 of 22 (13.6%) SCD-treated patients, 1 of 23 (4.3%) enoxaparin-treated patients, and 4 of 23 (17.4%) SCD/enoxaparin-treated patients. Differences were not statistically significant. Postoperative intracranial hemorrhage did not occur in patients in the SCD-treated group, whereas 5 of 46 patients receiving low-molecular weight heparin suffered clinically significant intracranial hemorrhage. The study was terminated because of the increased incidence of adverse events in the enoxaparin-treated groups. Enoxaparin therapy initiated at the time of anesthesia induction increases postoperative intracranial hemorrhage.Neurosurgery 12/1998; 43(5):1074-81. DOI:10.1097/00006123-199811000-00039 · 3.03 Impact Factor