How is VTE managed in patients with glioblastoma multiforme (GBM)?

Updated: Jul 28, 2021
  • Author: Jeffrey N Bruce, MD; Chief Editor: Herbert H Engelhard, III, MD, PhD, FACS, FAANS  more...
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Answer

Approximately 20% of glioblastoma patients experience VTE in the year following surgical resection. [8] Prevention and treatment of VTE in these patients is complicated by their increased risk for intracranial hemorrhage (ICH). Therapeutic anticoagulation may increase risk of ICH in patients with primary brain tumors, but lack of long-term anticoagulation has been associated with an increased risk of recurrent VTE in patients with glioblastoma.American Society of Clinical Oncology (ASCO) guidelines recommend anticoagulation for patients with primary brain malignancies and an established VTE, although because of limited data on this population, uncertainties remain about the choice of anticoagulant and selection of patients most likely to benefit. [109]

For cancer patients generally, ASCO guidelines recommend that those undergoing major surgery receive VTE prophylaxis with either unfractionated heparin or low molecular weight heparin (LMWH), unless contraindicated (eg, because of active bleeding or high bleeding risk). [109] In patients with systemic cancer, prophylaxis is started preoperatively; because of the risk of ICH, however, prophylaxis in glioblastoma patients is started within 24 hours after surgery. [9] Prophylaxis is continued for at least 7 to 10 days postoperatively. [109]

ASCO guidelines include direct oral anticoagulants (DOACs) as an option for VTE prophylaxis and treatment, but note an increased risk of major bleeding. [109] However, a retrospective study by Carney et al found that in patients with primary brain tumors, the incidence of major hemorrhage was significantly lower with use of DOACs compared with LMWH. These authors concluded that DOACs are a reasonable option for treatment of VTE in this population. [110]


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