Increased risk of preoperative venous thromboembolism in patients with renal cell carcinoma and tumor thrombus: reply

Abstract

We thank Drs Gonzalez and Cianco for their interesting comments on the risk of preoperative venous thromboembolism (VTE) in patients with renal cell carcinoma and tumor thrombus 1.Conzalez J. Ciancia G. Increased risk of pre‐operative venous thromboembolism in patients with renal cell carcinoma and tumor thrombus: Comment.J Thromb Haemost. 2014; 12: 577-8Abstract Full Text Full Text PDF Scopus (2) Google Scholar. As discussed in our manuscript, the primary outcome of the study was the rate of lower extremity deep vein thrombus (DVT) or pulmonary embolism (PE) in the preoperative period and not the coexistence of bland thrombus with tumor thrombus at the time of diagnosis 2.Yokom D.W. Ihaddadene R. Moretto P. Canil C.M. Reaume N. Le Gal G. Carrier M. Increased risk of pre‐operative venous thromboembolism in patients with renal cell carcinoma and tumor thrombus.J Thromb Haemost. 2014; 12: 169-71Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar. Our primary outcome measure was defined and reported as recommended by the International Society of Thrombosis and Haemostasis (ISTH) SSC Haemostasis & Malignancy 3.Carrier M. Khorana A.A. Zwicker J.I. Lyman G.H. Le Gal G. Lee A.Y. subcommittee on Haemostasis and Malignancy for the SSC of the ISTHVenous thromboembolism in cancer clinical trials: recommendation for standardized reporting and analysis.J Thromb Haemost. 2012; 10: 2599-601Crossref PubMed Scopus (31) Google Scholar. Venous thromboembolism was defined as proximal lower extremity (popliteal vein or more proximal) DVT or PE. Proximal DVT and PE were diagnosed by compressive ultrasound and computed tomographic pulmonary angiography, respectively. Therefore, the risks specifically associated with bland thrombus within tumor thrombus were not evaluated in our manuscript. As highlighted by Dr Gonzalez, the clinical relevance and importance of the presence of asymptomatic bland thrombus within the tumor thrombus is uncertain (e.g. need for anticoagulation). Hence, we aimed to assess the risk of VTE in patients presenting with suspected events. The diagnostic imaging used to identify renal cell cancer patients with or without tumor thrombus in our study was the initial radiographic confirmation of the diagnosis of renal cell carcinoma and not necessarily the imaging used for planning the patient's surgery. If indicated, patients received further imaging at the discretion of their surgeon. However, this was outside the scope of our study. Although the clinical significance of bland thrombus co‐existing with tumor thrombus is unclear for patients with renal cell carcinoma, this is not the case for VTE. Patients with recent (< 3 months) proximal lower extremity DVT and/or PE are considered at high risk of a recurrent event in the perioperative period and an elective surgical intervention might have to be delayed to complete a period of anticoagulation 4.Douketis J.D. Spyropoulos A.C. Spencer F.A. Mayr M. Jaffer A.K. Eckman M.H. Dunn A.S. Kunz R. American College of Chest PhysiciansPerioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence‐Based Clinical Practice Guidelines.Chest. 2012; 141: e326S-50SAbstract Full Text Full Text PDF PubMed Scopus (1298) Google Scholar. We agree that the risk of major bleeding episodes is increased in cancer patients receiving anticoagulation treatment 5.Prandoni P. Lensing A.W. Piccioli A. Bernardi E. Simioni P. Girolami B. Marchiori A. Sabbion P. Prins M.H. Noventa F. Girolami A. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis.Blood. 2002; 100: 3484-8Crossref PubMed Scopus (1481) Google Scholar but the case fatality rate of untreated PE is extremely high in the acute period following the VTE diagnosis 6.Barritt D.W. Jordan S.C. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial.Lancet. 1960; 1: 1309-12Abstract PubMed Scopus (1093) Google Scholar and we strongly recommend anticoagulation. The time to perform radical nephrectomy and tumor thrombus resection in patients with renal cell carcinoma and acute symptomatic proximal DVT or PE should be decided on a case by case basis after careful evaluation of the risks and benefits. Pulmonary endarterectomy under cardiopulmonary bypass should not be performed routinely. The authors state that they have no conflicts of interest.