Patients at Risk for Coagulation After Thoracic Resection

Lara C. Pullen, PhD

October 08, 2015

CHICAGO — Patients with lung or esophageal malignancy may have hypercoagulability that is associated with increased platelet activity. In the case of lung malignancies, hypercoagulability can be detected preoperatively and does not reverse after complete resection. In contrast, in cases of esophageal malignancy, hypercoagulability occurs postoperatively.

"It will be interesting to see if aspirin in addition to enoxaparin (Lovenox, sanofi-aventis) is of value," stated Robert M. Van Haren, MD, MSPH, of the University of Miami Miller School of Medicine, in Florida, when discussing the implications of his findings. Thromboembolic disease has long been recognized as an early clinical sign of an underlying malignancy, he commented.

Dr Van Haren presented the results of his prospective evaluation of coagulation parameters here at the American College of Surgeons (ACS) Clinical Congress 2015. The investigators evaluated 38 patients with lung and esophageal malignancy and performed clotting analysis on blood collected preoperatively, at postoperative day 1, and at follow-up clinic 1 to 2 weeks after operation. The investigators used the ROTEM analysis (which measures thromboelastometry) and impedance aggregometry to perform a point-of-care test on whole blood.

The average age of the patients was 66 years. The average body mass index score was 26 ± 5, and 76% of the patients were men. Two thirds had esophageal cancer, and one third had lung cancer.

In comparing the patients with esophageal cancer with the patients with lung cancer, the researchers found that although both groups were of the same age, the patients with esophageal cancer were more likely to be male and to have undergone open surgeries. Rates of venous thromboembolism (VTE) and mortality were similar for both groups.

Three patients in the study developed VTE (two with esophageal cancer and one with lung cancer). All patients were symptomatic.

When the investigators compared the ROTEM values of the patients who experienced VTE with the patients who did not, they found that the ROTEM values were similar.

The team also found that thoracic malignancy coagulation status depended upon tumor type/stage. In the case of esophageal cancer, hypercoagulability was not clearly affected by stage. However, in the case of lung cancer, later stages were associated with increased maximum clot formation and angle (increased platelet and fibrin activity) (P < .05) and thus increased rates of hypercoagulability.

Table. Hypercoagulability Rates

Patients Preoperative Postoperative P-value
Esophageal 16% 62% 0.002
Lung 56% 39% 0.375


"...[I]t was kind of surprising that the lung cancer patients had higher rates of coagulability," Dr Van Haren commented. He noted that the study was limited by small sample size and lack of long-term blood samples.

"These authors have attempted to tackle a very germane topic," noted discussant Sudish Murthy, MD, PhD, of the Cleveland Clinic, in Ohio. He added that his group struggles to find the optimal thromboprophylaxis regimen for patients after surgery.

Dr Murthy raised the possibility that rates of hypercoagulability might be increased in the patients who underwent esophagectomy as a result of the tricky procedure and not the cancer itself.

Dr Van Haren agreed that this was a possibility and acknowledged that they had not included benign esophagectomy patients as a control measure.

Although Dr Van Haren expressed interest in the idea of adding aspirin to a thromboprophylaxis regimen, he acknowledged that future studies are needed to determine the efficacy of such an approach. Dr Murthy countered by stating, "The real issue is a more definitive anticoagulant."

Neither Dr Van Haren nor Dr Murthy have reported any relevant financial relationships.

American College of Surgeons (ACS) Clinical Congress 2015: Presented October 7, 2015.


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