Radiation Oncology/Supportive care/Thromboembolism

Brain Metastases Brain hemorrhage risk higher with brain mets and anticoagulation Treatment is thus a judgment call between risk of brain hemorrhage vs. risk of death/complications from thromboembolism MSKCC data suggests <10% risk of significant CNS complications on anticoagulation. Caution with hemorrhagic histologies It is important not to reach supratherapeutic levels; LMWH is probably safer from that perspective Gamma Knife treatment is not considered a contraindication MSKCC, 1994 PMID 8293418 -- "Therapy of venous thromboembolism in patients with brain metastases." (Schiff D, Cancer. 1994 Jan 15;73(2):493-8.) Retrospective. 51 patients, 10 treated with IVC, 39 treated with anticoagulation, 2 not treated (both died of PE) IVCF: 4/10 recurrent nonfatal thromboembolic events (2 PEs, 2 DVTs) -> 3/4 required secondary anticoagulation Anticoagulation: 39 as primary therapy + 3 secondary after IVCF failure. 2/42 patients devastating CNS hemorrhage in the setting of supratherapeutic anticoagulation, 1/42 minor deterioration (overall 7% incidence of CNS complications on anticoagulation). 3/42 asymptomatic with hyperdensity on CT Conclusion: Anticoagulation more effective than IVC. Acceptably safe when maintained within therapeutic range Review Hopkins, 2006 PMID 16525187 -- "Management of venous thromboembolism in patients with primary and metastatic brain tumors." (Gerber DE, J Clin Oncol. 2006 Mar 10;24(8):1310-8.) Anticoagulation can be used safely and effectively for most patients; IC hemorrhage often due to overanticoagulation High risk patients: thrombocytopenia, recent neurosurgery, tumor types prone to bleeding (renal cell, melanoma, choriocarcinoma, thyroid cancer) are relative contraindication Mechanical approaches have high complication rate and high failure rates, but can be used if cannot anti-coagulate Antithrombolytic agents are absolute contraindication Treatment recommendation: High risk (craniotomy within 3-5 days, high risk histology, recent bleeding): IVCF Acute/progressive symptoms: mini-heparin bolus (40 U/kg IV) or full heparin bolus (80 U/kg IV) for 24 hours depending on severity of TE symptoms. Careful monitoring of therapeutic level. Then long-term LMWH or warfarin Standard risk (eg DVT): IV heparin (no bolus) for 24 hours, then long-term LMWH or warfarin Paris, 2005 (France) PMID 16224238 -- "Palliative care in patients with brain metastases." (Taillibert S, Curr Opin Oncol. 2005 Nov;17(6):588-92.) Prophylaxis: recommended if decreased mobility, with LMWH Symptomatic DVH: anticoagulation safe; recommend LMWH due to lack of interaction with chemo and convenience Hemorrhagic mets: unless active bleeding, can anticoagulate, but requires strict monitoring Avoid NSAIDs and Vitamin K