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Treatment of Venous Thrombosis in Patients With Intracranial Malignancies

South Shore Hematology-Oncology Associates, Rockville Centre, NY

To the Editor:

Although carefully worded, I believe that the American Society of Clinical Oncology guideline for prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer gives the wrong message in regard to patients with intracranial malignancy.¹ The guideline suggests that in the absence of active intracranial bleeding, anticoagulation is not absolutely contraindicated, and that heparin and warfarin "have been shown to effectively reduce the risk of VTE without an increase in rates of intracranial bleeding." However, that assessment is based on several very small case studies, most of which contained few patients with brain metastases using anticoagulation regimens of various intensity and duration. The largest study that included patients with brain metastases had a rate of intracranial hemorrhage of 7% among 42 patients, which gives a 95% CI of 1.5% to 19.5%.² The risk for patients with specific tumor types with a propensity for hypervascularity, such as melanoma and renal cell carcinoma, might be even higher. I think a more cautious statement for a guideline would be that devastating intracranial hemorrhage has been reported in patients with intracranial malignancies treated with anticoagulation, especially those with brain metastases in whom supratherapeutic levels of anticoagulation were obtained. The safety of low molecular weight heparin in this setting is untested. The risk of intracranial hemorrhage must be weighed against the risk of death from pulmonary embolism and the complications of inferior vena cava filters. A randomized clinical trial to assess the best treatment for these patients would be warranted.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Lyman GH, Khorana AA, Clarke-Pearson D, et al: American Society of Clinical Oncology guideline: Recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 25:5490-5505, 2007[Abstract/Free Full Text]

2. Schiff D, DeAngelis LM: Therapy of venous thromboembolism in patients with brain metastases. Cancer 73:493-498, 1994[CrossRef][Medline]

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  Alok A. Khorana, Charles W. Francis, Anna Falanga, and Gary H. Lyman
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