Shang-Wen Tsai, Te-Feng Arthur Chou, Wei-Ming Chen.
Response/Recommendation: Patients undergoing resection procedures for bone metastasis or procedures that involve prosthesis reconstruction are at higher risk of venous thromboembolism and require routine prophylaxis.
Strength of Recommendation: Limited.
Rationale: Most of the current literature that evaluated the risk of venous thromboembolism (VTE) after musculoskeletal oncology procedures were for primary and metastatic tumors involving the lower extremities1–14. In studies that administered only mechanical prophylaxis or only had a low proportion of patients that received pharmacologic thromboprophylaxis, the VTE rates (2.7% – 23.4%) were higher when compared with studies that administered pharmacologic prophylaxis in most or all of the patients (1.1 – 6.3%) 1–4,6–14. However, clinical heterogeneity (e.g. tumor characteristics, including primary or metastatic tumor, benign or malignant tumor, soft tissue or bone tumor, tumor location, type of surgical procedure, agents for thromboprophylaxis, a protocol for VTE surveillance) across studies made it difficult to have a direct comparison of VTE rates between patients who received pharmacologic thromboprophylaxis with those that did not receive prophylaxis.
Several studies have identified certain tumor characteristics or procedure types as risk factors for VTE events. These include prosthesis reconstruction procedures11,15, tumors located in the pelvis13, hip or thigh12, and bone metastasis1,5. Three large retrospective case series administered pharmacologic thromboprophylaxis in most of the patients (75.7% – 100%) and validated relatively low VTE rates (1.1% – 4.6%) following prosthesis reconstruction after resection of primary malignant and metastatic lower limb tumors (mostly, around hip and knee joints), suggesting that pharmacologic thromboprophylaxis was effective for these complex procedures6,9,13.
Three large, retrospective case series reported VTE rates in patients who had been surgically treated for skeletal metastasis, including spinal16 and non-spinal metastasis17,18. Most of the patients (79% – 86%) received pharmacologic thromboprophylaxis. The overall VTE rates were high (6 – 11.4%)16–18. Risk factors for VTE included the presence of pulmonary metastasis18, intraoperative desaturation18, and longer surgery duration16. The results for intramedullary nailing as a risk factor VTE were inconclusive17,18. Despite the need for thromboprophylaxis in patients with high VTE risks, individualized evaluation and weighing the potential risk of bleeding with the benefits of thromboprophylaxis is required. For patients who are not able to receive pharmacologic prevention due to a high risk for bleeding, a combination of inferior vena cava filter and mechanical compression device might be an effective alternative11,19.
Currently, there is a lack of high-quality studies to conclude a specific population with regards to tumor characteristics or procedure type that requires prophylaxis. However, there is some evidence to support that patients undergoing resection procedures for bone metastasis or procedures that involve prosthesis reconstruction require prophylaxis because of a higher VTE risk.
References:
1. Mioc M-L, Prejbeanu R, Vermesan D, et al. Deep vein thrombosis following the treatment of lower limb pathologic bone fractures – a comparative study. BMC Musculoskelet Disord. 2018;19(1):213. doi:10.1186/s12891-018-2141-4
2. Kaiser CL, Freehan MK, Driscoll DA, Schwab JH, Bernstein KDA, Lozano-Calderon SA. Predictors of venous thromboembolism in patients with primary sarcoma of bone. Surg Oncol. 2017;26(4):506-510. doi:10.1016/j.suronc.2017.09.007
3. Mendez GM, Patel YM, Ricketti DA, Gaughan JP, Lackman RD, Kim TWB. Aspirin for Prophylaxis Against Venous Thromboembolism After Orthopaedic Oncologic Surgery. J Bone Joint Surg Am. 2017;99(23):2004-2010. doi:10.2106/JBJS.17.00253
4. Yamaguchi T, Matsumine A, Niimi R, et al. Deep-vein thrombosis after resection of musculoskeletal tumours of the lower limb. Bone Joint J. 2013;95-B(9):1280-1284. doi:10.1302/0301-620X.95B9.30905
5. Kim SM, Park JM, Shin SH, Seo SW. Risk factors for post-operative venous thromboembolism in patients with a malignancy of the lower limb. Bone Joint J. 2013;95-B(4):558-562. doi:10.1302/0301-620X.95B4.30416
6. Ramo BA, Griffin AM, Gill CS, et al. Incidence of symptomatic venous thromboembolism in oncologic patients undergoing lower-extremity endoprosthetic arthroplasty. J Bone Joint Surg Am. 2011;93(9):847-854. doi:10.2106/JBJS.H.01640
7. Damron TA, Wardak Z, Glodny B, Grant W. Risk of venous thromboembolism in bone and soft-tissue sarcoma patients undergoing surgical intervention: a report from prior to the initiation of SCIP measures. J Surg Oncol. 2011;103(7):643-647. doi:10.1002/jso.21884
8. Patel AR, Crist MK, Nemitz J, Mayerson JL. Aspirin and compression devices versus low-molecular-weight heparin and PCD for VTE prophylaxis in orthopedic oncology patients. J Surg Oncol. 2010;102(3):276-281. doi:10.1002/jso.21603
9. Ruggieri P, Montalti M, Pala E, et al. Clinically significant thromboembolic disease in orthopedic oncology: an analysis of 986 patients treated with low-molecular-weight heparin. J Surg Oncol. 2010;102(5):375-379. doi:10.1002/jso.21645
10. Morii T, Mochizuki K, Tajima T, Aoyagi T, Satomi K. Venous thromboembolism in the management of patients with musculoskeletal tumor. J Orthop Sci. 2010;15(6):810-815. doi:10.1007/s00776-010-1539-0
11. Tuy B, Bhate C, Beebe K, Patterson F, Benevenia J. IVC filters may prevent fatal pulmonary embolism in musculoskeletal tumor surgery. Clin Orthop Relat Res. 2009;467(1):239-245. doi:10.1007/s11999-008-0607-7
12. Mitchell SY, Lingard EA, Kesteven P, McCaskie AW, Gerrand CH. Venous thromboembolism in patients with primary bone or soft-tissue sarcomas. J Bone Joint Surg Am. 2007;89(11):2433-2439. doi:10.2106/JBJS.F.01308
13. Nathan SS, Simmons KA, Lin PP, et al. Proximal deep vein thrombosis after hip replacement for oncologic indications. J Bone Joint Surg Am. 2006;88(5):1066-1070. doi:10.2106/JBJS.D.02926
14. Lin PP, Graham D, Hann LE, Boland PJ, Healey JH. Deep venous thrombosis after orthopedic surgery in adult cancer patients. J Surg Oncol. 1998;68(1):41-47. doi:10.1002/(sici)1096-9098(199805)68:1<41::aid-jso9>3.0.co;2-l
15. Ogura K, Yasunaga H, Horiguchi H, Ohe K, Kawano H. Incidence and risk factors for pulmonary embolism after primary musculoskeletal tumor surgery. Clin Orthop Relat Res. 2013;471(10):3310-3316. doi:10.1007/s11999-013-3073-9
16. Groot OQ, Ogink PT, Paulino Pereira NR, et al. High Risk of Symptomatic Venous Thromboembolism After Surgery for Spine Metastatic Bone Lesions: A Retrospective Study. Clin Orthop Relat Res. 2019;477(7):1674-1686. doi:10.1097/CORR.0000000000000733
17. Groot OQ, Ogink PT, Janssen SJ, et al. High Risk of Venous Thromboembolism After Surgery for Long Bone Metastases: A Retrospective Study of 682 Patients. Clin Orthop Relat Res. 2018;476(10):2052-2061. doi:10.1097/CORR.0000000000000463
18. Ratasvuori M, Lassila R, Laitinen M. Venous thromboembolism after surgical treatment of non-spinal skeletal metastases – An underdiagnosed complication. Thromb Res. 2016;141:124-128. doi:10.1016/j.thromres.2016.03.013
19. Benevenia J, Bibbo C, Patel DV, Grossman MG, Bahramipour PF, Pappas PJ. Inferior vena cava filters prevent pulmonary emboli in patients with metastatic pathologic fractures of the lower extremity. Clin Orthop Relat Res. 2004;(426):87-91. doi:10.1097/01.blo.0000131641.89360.f2