Preoperative vena caval interruption for venous thrombosis associated with ovarian malignancy

High incidence of silent venous thromboembolism before treatment in ovarian cancer

Venous thromboembolism (VTE) such as deep-vein thrombosis (DVT) and pulmonary thromboembolism (PTE) often occurs after surgery and rarely occurs even before surgery in patients with ovarian cancer. It is well known that levels of plasma D-dimer (DD) before treatment in most ovarian cancer patients are increased. This study therefore examined whether increased levels of DD are associated with presence of VTE before treatment of ovarian cancer. Between November 2004 and March 2007, DD levels prior to initial treatment were measured in 72 consecutive patients with presumed epithelial ovarian cancer (final diagnosis: epithelial ovarian cancer, n=60; and epithelial ovarian borderline malignancy, n=12). Venous ultrasound imaging (VUI) of the lower extremity was conducted for all patients except for two patients in whom DVT was detected by pelvic computed tomography (CT). When DVT was found, pulmonary scintigraphy was subsequently performed to ascertain presence of PTE. D-dimer levels were above the cut-off value (0.5 μg ml⁻¹) in 65 of 72 patients (90.2%). Venous ultrasound imaging or CT revealed DVT in 18 of 72 patients (25.0%) and pulmonary scintigraphy found PTE in 8 patients (11.1%). All patients with VTE were asymptomatic when VTE was found. D-dimer levels were associated with incidence of VTE (0–1.4 μg ml⁻¹; 0 of 26 (0%), 1.5–7.4 μg ml⁻¹; 9 of 30 (30%) and ⩾7.5 μg ml⁻¹; 9 of 16 (56.3%), P for trend=0.0003). However, even if 1.5 μg ml⁻¹ was used as a cut-off value, this had low specificity and positive predictive value (47.2, 38.3%), though it had high sensitivity and negative predictive value (100, 100%). Therefore, ovarian cancer patients with DD level ⩾1.5 μg ml⁻¹ should be examined using VUI to detect silent DVT. Patients with VTE underwent preventive managements including anticoagulant therapy before initial treatment, chemotherapy or surgery, and after surgery. There was no clinical onset of postoperative VTE in all 72 patients. Measurement of DD levels and subsequent ultrasonography revealed that silent or subclinical VTE frequently occurs before surgery in ovarian cancer. The usefulness of preoperative assessment of VTE needs further confirmation in randomised controlled trials.

Thromboembolic complications in patients with clear cell carcinoma of the ovary

OBJECTIVE

The purpose of this study was to define the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients with clear cell carcinoma (CCC) of the ovary and to investigate the prognostic factors in such patients.

METHODS

Between January 1987 and December 2003, 641 women with primary invasive epithelial ovarian cancer underwent treatment at the Royal Hospital for Women in Sydney, Australia. Sixty-six patients (10.3%) with CCC were identified from the data bank, and their data were compared with a matched-control group of 132 patients with non-clear cell epithelial ovarian carcinoma.

RESULTS

A thromboembolic event (DVT or PE) was noted in 27.3% of patients with CCC, compared to 6.8% of patients with other epithelial ovarian cancers. PE was detected in 13.6% and 3.8% of patients, respectively. In patients with CCC, DVT was frequently observed before operation or at the time of recurrence. In a multivariate analysis of patients matched for age and stage, the occurrence of a DVT or the presence of endometriosis was significant predictors of clear cell histology. Within the clear cell group, no particular risk factor for DVT could be identified. Metastases of 50 mm or greater in diameter, ascites of 1000 ml or more, advanced FIGO stage, and the occurrence of DVT were poor prognostic factors for CCC in univariate analysis, but in a multivariate Cox regression analysis, only FIGO stage and occurrence of DVT remained significant.

CONCLUSION

The incidence of venous thromboembolic events was found to be significantly higher in patients with CCC when compared to patients with other epithelial ovarian cancers.