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Prevention and treatment of venous thromboembolism in patients with solid brain neoplasms: results of a survey among Italian physicians

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Abstract

The decision concerning the introduction of primary and secondary prophylaxis of venous thromboembolism (VTE) in patients with solid brain neoplasms and brain metastases is often challenging due to the concomitant increased risk of intracranial hemorrhage and to limited evidence from available literature. A standardized questionnaire composed of nine multiple-choice questions regarding primary VTE prevention in non-surgical patients during high-risk conditions and VTE secondary prevention in patients with a solid brain neoplasm or cerebral metastases was sent via electronic mail to all the members (n = 2420) of the Italian Federation of the Internal Medicine Hospital Executives’ Associations (FADOI) in June 2015. Three hundred and fifty two physicians (14.5%) returned it (participants' median age 51 years; females 46.9%). The majority of respondents prescribe primary thromboprophylaxis (usually with heparin) in non-surgical patients with solid brain neoplasms and brain metastases in concomitance with high-risk conditions. Full-dose anticoagulation with either low-molecular-weight heparin or fondaparinux is the preferred option for acute VTE (69.6%), while a reduced dose is chosen by 21.0% of physicians. The presence of a highly vascular brain neoplasm histotype mandates the prescription of a reduced-dose antithrombotic regimen in a minority of respondents. Vena cava filter placement is an option for the treatment of acute VTE in more than 6% of respondents. Anticoagulants are often prescribed for both VTE primary prevention and treatment. In conclusion, physicians’ managements are partially in contrast to recent guidelines, reinforcing the need for educational programs and other studies in this setting.

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References

  1. Portillo J, de la Rocha IV, Font L, Braester A, Madridano O, Peromingo JA et al (2015) Venous thromboembolism in patients with glioblastoma multiforme: findings of the RIETE registry. Thromb Res 136(6):1199–1203

    Article  CAS  PubMed  Google Scholar 

  2. Petterson TM, Marks RS, Ashrani AA, Bailey KR, Heit JA (2015) Risk of site-specific cancer in incident venous thromboembolism: a population-based study. Thromb Res 135(3):472–478

    Article  CAS  PubMed  Google Scholar 

  3. Walker AJ, Card TR, West J, Crooks C, Grainge MJ (2013) Incidence of venous thromboembolism in patients with cancer—a cohort study using linked United Kingdom databases. Eur J Cancer 49(6):1404–1413

    Article  PubMed  Google Scholar 

  4. Weinstock MJ, Uhlmann EJ, Zwicker JI (2016) Intracranial hemorrhage in cancer patients treated with anticoagulation. Thromb Res 140(Suppl 1):S60–S65

    Article  CAS  PubMed  Google Scholar 

  5. Sorensen HT, Mellemkjaer L, Steffensen FH, Olsen JH, Nielsen GL (1998) The risk of a diagnosis of cancer after primary deep venous thrombosis or pulmonary embolism. N Engl J Med 338(17):1169–1173

    Article  CAS  PubMed  Google Scholar 

  6. Khoury MN, Missios S, Edwin N, Sakruti S, Barnett G, Stevens G et al (2016) Intracranial hemorrhage in setting of glioblastoma with venous thromboembolism. Neurooncol Pract. 3(2):87–96

    Google Scholar 

  7. Donato J, Campigotto F, Uhlmann EJ, Coletti E, Neuberg D, Weber GM et al (2015) Intracranial hemorrhage in patients with brain metastases treated with therapeutic enoxaparin: a matched cohort study. Blood 126(4):494–499

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Jo JT, Schiff D, Perry JR (2014) Thrombosis in brain tumors. Semin Thromb Hemost 40(3):325–331

    Article  CAS  PubMed  Google Scholar 

  9. Perry JR, Julian JA, Laperriere NJ, Geerts W, Agnelli G, Rogers LR et al (2010) PRODIGE: a randomized placebo-controlled trial of dalteparin low-molecular-weight heparin thromboprophylaxis in patients with newly diagnosed malignant glioma. J Thromb Haemost 8(9):1959–1965

    Article  CAS  PubMed  Google Scholar 

  10. Perry SL, Bohlin C, Reardon DA, Desjardins A, Friedman AH, Friedman HS et al (2009) Tinzaparin prophylaxis against venous thromboembolic complications in brain tumor patients. J Neurooncol 95(1):129–134

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Dickinson LD, Miller LD, Patel CP, Gupta SK (1998) Enoxaparin increases the incidence of postoperative intracranial hemorrhage when initiated preoperatively for deep venous thrombosis prophylaxis in patients with brain tumors. Neurosurgery. 43(5):1074–1081

    Article  CAS  PubMed  Google Scholar 

  12. Iorio A, Agnelli G (2000) Low-molecular-weight and unfractionated heparin for prevention of venous thromboembolism in neurosurgery: a meta-analysis. Arch Intern Med 160(15):2327–2332

    Article  CAS  PubMed  Google Scholar 

  13. Robins HI, O’Neill A, Gilbert M, Olsen M, Sapiente R, Berkey B et al (2008) Effect of dalteparin and radiation on survival and thromboembolic events in glioblastoma multiforme: a phase II ECOG trial. Cancer Chemother Pharmacol 62(2):227–233

    Article  CAS  PubMed  Google Scholar 

  14. Agnelli G, Gussoni G, Bianchini C, Verso M, Mandala M, Cavanna L et al (2009) Nadroparin for the prevention of thromboembolic events in ambulatory patients with metastatic or locally advanced solid cancer receiving chemotherapy: a randomised, placebo-controlled, double-blind study. Lancet Oncol. 10(10):943–949

    Article  CAS  PubMed  Google Scholar 

  15. Lee AY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M et al (2003) Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 349(2):146–153

    Article  CAS  PubMed  Google Scholar 

  16. Lee AY, Kamphuisen PW, Meyer G, Bauersachs R, Janas MS, Jarner MF et al (2015) Tinzaparin vs warfarin for treatment of acute venous thromboembolism in patients with active cancer: a randomized clinical trial. JAMA 314(7):677–686

    Article  CAS  PubMed  Google Scholar 

  17. Hull RD, Pineo GF, Brant RF, Mah AF, Burke N, Dear R et al (2006) Long-term low-molecular-weight heparin versus usual care in proximal-vein thrombosis patients with cancer. Am J Med 119(12):1062–1072

    Article  CAS  PubMed  Google Scholar 

  18. Meyer G, Marjanovic Z, Valcke J, Lorcerie B, Gruel Y, Solal-Celigny P et al (2002) Comparison of low-molecular-weight heparin and warfarin for the secondary prevention of venous thromboembolism in patients with cancer: a randomized controlled study. Arch Intern Med 162(15):1729–1735

    Article  CAS  PubMed  Google Scholar 

  19. Zwicker JI, Karp RL, Carrier M (2016) A meta-analysis of intracranial hemorrhage in patients with brain tumors receiving therapeutic anticoagulation. J Thromb Haemost 14(9):1736–1740

    Article  CAS  PubMed  Google Scholar 

  20. Edwin NC, Khoury MN, Sohal D, McCrae KR, Ahluwalia MS, Khorana AA (2016) Recurrent venous thromboembolism in glioblastoma. Thromb Res 137:184–188

    Article  CAS  PubMed  Google Scholar 

  21. Akl EA, Kahale L, Neumann I, Barba M, Sperati F, Terrenato I et al (2014) Anticoagulation for the initial treatment of venous thromboembolism in patients with cancer. Cochrane Database Syst Rev 6:CD006649

    Google Scholar 

  22. Alvarado G, Noor R, Bassett R, Papadopoulos NE, Kim KB, Hwu WJ et al (2012) Risk of intracranial hemorrhage with anticoagulation therapy in melanoma patients with brain metastases. Melanoma Res 22(4):310–315

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA et al (2012) Prevention of VTE in nonsurgical patients: antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e195S–e226S

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H et al (2016) Antithrombotic therapy for VTE disease: CHEST Guideline and Expert Panel Report. Chest 149(2):315–352

    Article  PubMed  Google Scholar 

  25. Khorana AA, Carrier M, Garcia DA, Lee AY (2016) Guidance for the prevention and treatment of cancer-associated venous thromboembolism. J Thromb Thrombolysis 41(1):81–91

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Farge D, Debourdeau P, Beckers M, Baglin C, Bauersachs RM, Brenner B et al (2013) International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J Thromb Haemost 11(1):56–70

    Article  CAS  PubMed  Google Scholar 

  27. Lyman GH, Bohlke K, Khorana AA, Kuderer NM, Lee AY, Arcelus JI et al (2015) Venous thromboembolism prophylaxis and treatment in patients with cancer: american society of clinical oncology clinical practice guideline update 2014. J Clin Oncol 33(6):654–656

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Lyman GH, Khorana AA, Kuderer NM, Lee AY, Arcelus JI, Balaban EP et al (2013) Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 31(17):2189–2204

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We thank all the respondents for the time they devoted to complete the questionnaire and the Executive Committee of the FADOI for their help in promoting this survey. The work of Stefano Barco is supported by the German Federal Ministry of Education and Research (BMBF 01EO1003 and 01EO1503).

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Authors and Affiliations

  1. Department of Internal Medicine, Ospedale Civile di Livorno, Viale Alfieri, 36, 57124, Livorno, Italy

    Nicola Mumoli & Marco Cei

  2. Center for Thrombosis and Hemostasis, Johannes Gutenberg University, Mainz, Germany

    Stefano Barco

  3. Emergency Department, Ospedale della Val d’Arda, Piacenza, Italy

    Matteo Giorgi-Pierfranceschi

  4. Department of Internal Medicine, Ospedale Maggiore della Carità, Novara, Italy

    Mauro Campanini

  5. Department of Internal Medicine, Ospedale Fatebenefratelli, Napoli, Italy

    Andrea Fontanella

  6. Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy

    Walter Ageno & Francesco Dentali

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  1. Nicola Mumoli
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  2. Stefano Barco
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  3. Marco Cei
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  8. Francesco Dentali
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Correspondence to Nicola Mumoli.

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The authors declare that they have no conflict of interest.

Statement of human and animal rights

The study procedures were in accordance with the ethical standards of the latest Helsinki declaration.

Informed consent

All the participants provided written consent for their participation in this survey at the time of online data collection. Due to the anonymous and voluntary nature of the study, no identifying information about participants was mandatory for inclusion.

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Mumoli, N., Barco, S., Cei, M. et al. Prevention and treatment of venous thromboembolism in patients with solid brain neoplasms: results of a survey among Italian physicians. Intern Emerg Med 12, 437–443 (2017). https://doi.org/10.1007/s11739-016-1578-4

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  • DOI: https://doi.org/10.1007/s11739-016-1578-4

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