ASO Author Reflections: Venous Thromboembolism in a Patient with Musculoskeletal Tumor: Fact or Fiction?
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Venous Thromboembolism in a Patient with Musculoskeletal Tumor: Fact or Fiction? Shintaro Iwata, MD Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center Japan, Tokyo, Japan
PAST
PRESENT
In 1856, the German pathologist Rudolph Virchow described three factors that contribute to the development of venous thromboembolism (VTE): venous stasis, hypercoagulability, and vessel wall injury.1 Orthopedic oncologists have been careful to avoid the development of VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE). Surgical procedures during bone and soft tissue tumor removal adjacent to blood vessels can result in injury to the vascular endothelium. Compression of blood vessels by a bulky tumor, longer operation time, and postoperative immobility of the affected limb lead to blood flow stagnation. In addition to these, the fact that malignancy is associated with a hypercoagulable state reminds us that patients with musculoskeletal malignancies are considered to have a very high risk of developing VTE. Previous reports have demonstrated a relatively higher incidence of VTE in patients who underwent surgery for musculoskeletal malignancies (* 17%), compared with other major orthopedic surgery.2,3 On the other hand, there are some reports that the incidence of VTE in patients with musculoskeletal malignancies is comparable to that of patients undergoing joint replacement or trauma surgery.4 Actually, whether the hypercoagulable state is truly associated with sarcoma remains unclear.
This prospective multi-center observational cohort study included 929 patients newly diagnosed as having primary high-grade bone and soft tissue sarcomas who underwent surgery with curative intent between 2012 and 2015. The patients were followed carefully for at least 6 months after surgery. The primary endpoint of the study was the occurrence of symptomatic DVT and PE, which were confirmed by ultrasonography, CT angiography, or lung scintigraphy.5 Eleven patients developed symptomatic VTE, including 8 patients with symptomatic DVT, 2 with PE, and 1 with both, making the incidence of symptomatic VTE, symptomatic DVT, and PE 1.18, 0.86, and 0.22%, respectively. These are lower than previously reported results for patients with sarcoma, and comparable to those of patients who have undergone arthroplasty in our country. On the other hand, predictive factor analysis showed that ischemic heart disease, tumor size, and elevation of the preoperative platelet count are risk factors for symptomatic VTE. Interestingly, these factors are quite different from those in patients who underwent arthroplasty.
Ó Society of Surgical Oncology 2020 First Received: 27 October 2020 Accepted: 28 October 2020 S. Iwata, MD e-mail: [email protected]
FUTURE Bone and soft tissue sarcoma are rare cancers and symptomatic VTE is a rare event. Therefore, it is essential to conduct an international collaborative study to solve the problem concerning VTE in sarcomas. The next question
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