Routine surveillance for diagnosis of venous thromboembolism after pleurectomy for malignant pleural mesothelioma

Our plain-English summary of Routine surveillance for diagnosis of venous thromboembolism after pleurectomy for malignant pleural mesothelioma, by L.E. De León, C.E. Bravo-Iñiguez, S. Fox, et al (The Journal of Thoracic and Cardiovascular Surgery, 2020).

The study

• Authors: L.E. De León, C.E. Bravo-Iñiguez, S. Fox, J. Tarascio, S. Freyaldenhoven, M. Lapidot, M.T. Jaklitsch, R. Bueno
• Journal: The Journal of Thoracic and Cardiovascular Surgery
• Published: 2020;160(4):1064-1073
• Cited by: 10 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objective: The purpose of this study was to determine the incidence of venous thromboembolism and utility of a routine surveillance program in patients undergoing surgery for mesothelioma.

Methods: Patients undergoing pleurectomy from May 2016 to August 2018 were included. A standardized surveillance program to look for venous thromboembolism in this group included noninvasive studies every 7 days postoperatively or earlier if symptomatic. All patients received external pneumatic compression sleeves in addition to prophylactic heparin. If deep vein thrombosis or pulmonary embolus was discovered, heparin drip was initiated until conversion to therapeutic anticoagulation.

Results: A total of 100 patients underwent pleurectomy for mesothelioma. Seven patients were found to have preoperative deep vein thrombosis, and as such only 93 patients were included for analysis. The median age of patients at surgery was 71 years (30-85 years). During the study, 30 patients (32%) developed evidence of thrombosis; 20 patients (22%) developed only deep vein thrombosis without embolism, 3 patients (3%) developed only pulmonary embolism, and 7 patients (7%) developed both deep vein thrombosis and pulmonary embolus. Of the 27 patients who developed deep vein thrombosis, 9 (33%) were asymptomatic at the time of diagnosis, and none of these developed a pulmonary embolus or other bleeding complications. There were 2 (2%) events of major postoperative bleeding related to therapeutic anticoagulation.

Conclusions: The incidence of venous thromboembolism is high (32%) among patients undergoing surveillance after pleurectomy for mesothelioma. Up to 33% of patients with deep vein thrombosis are asymptomatic at the time of diagnosis, and the incidence of complications related to anticoagulation is low. Routine surveillance may be useful to diagnose and treat deep vein thrombosis before it progresses to symptomatic or fatal pulmonary embolus.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

In plain English

This study followed patients having pleurectomy and decortication surgery for malignant pleural mesothelioma in Boston from May 2016 to August 2018. It measured how often vein blood clots (venous thromboembolism) formed. Of 100 patients, 7 already had a deep vein clot before surgery and were excluded, leaving 93. All received compression sleeves and heparin. Leg vein ultrasound was done on day 7 after surgery, or earlier for symptoms or discharge, and repeated every 7 days in patients without symptoms; arm veins were not routinely scanned unless symptoms appeared. Thirty patients (32%) developed a clot: 27 had deep vein thrombosis and 10 a pulmonary embolism (a lung clot), some both. Of the 27 with deep vein thrombosis, 9 (33%) had no symptoms when it was found. Seven patients (8%) had major bleeding; 2 of these, 2% of all 93 patients, were related to starting therapeutic anticoagulation. The authors concluded that routine surveillance can be implemented and may help find and treat symptom-free deep vein thrombosis before it becomes a symptomatic or fatal pulmonary embolism. They noted the study was single-center and some clots may have been missed.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Prospective single-center study of a routine surveillance protocol for venous thromboembolism after surgery
• Who was studied: 100 patients who had pleurectomy and decortication for malignant pleural mesothelioma at Brigham and Women's Hospital, Boston, May 2016 to August 2018. Seven had a deep vein thrombosis before surgery and were excluded, leaving 93 for analysis. Median age was 71 years (range 30-85), and 74 (80%) were male.
• Exposure: Pleurectomy and decortication surgery, followed by a surveillance protocol. Patients received compression sleeves and 5000 units of unfractionated heparin every 8 hours. Noninvasive vein studies were done on postoperative day 7, or earlier for symptoms or discharge readiness. Patients who remained without symptoms were followed with repeat studies every 7 days. The authors stated that upper-extremity studies were not done routinely unless symptoms appeared. The article does not study asbestos or fiber exposure.
• Main results:
  • Of the 93 patients, 30 (32%) developed venous thromboembolism: 20 (22%) had deep vein thrombosis only, 3 (3%) had pulmonary embolism only, and 7 (8%) had both.
  • Patients who remained without symptoms were followed with repeat studies every 7 days. Patients had a median of 1 noninvasive study (range 1-4) during their hospital stay.
  • The median time to any venous thromboembolism was 7 days after surgery (range 1-14 days).
  • Of the 27 patients with deep vein thrombosis, 9 (33%) had no symptoms at diagnosis. None of these 9 developed a pulmonary embolism or an anticoagulation-related complication.
  • All 12 patients with an upper-extremity deep vein thrombosis had the clot in a vein previously associated with a central line. Four (33%) of these 12 developed a pulmonary embolism.
  • Ten of the 93 patients (11%) developed a pulmonary embolism.
  • Seven patients (8% of the 93) had major postoperative bleeding. Two of these bleeding events, given as 2% of the cohort, were related to starting therapeutic anticoagulation.
  • The rate of venous thromboembolism did not differ statistically by intraoperative heated chemotherapy or by tumor histologic type.
  • Thirty-day mortality was 2% and operative mortality was 5%.
  • Hospital charges for each upper- or lower-extremity ultrasound study averaged $2103. Total estimated charges for all surveillance scans in the study period were $296,484.
• The authors' conclusion: The authors concluded that the surveillance protocol found a high (32%) incidence of venous thromboembolism despite standard prophylaxis. They concluded that routine noninvasive surveillance can be implemented and may help diagnose and treat asymptomatic deep vein thrombosis before it progresses to symptomatic or fatal pulmonary embolus. They called for further studies on the benefits and costs of surveillance and of prophylactic anticoagulation.
• Limitations the authors state:
  • The study cannot give reliable data on the best type, timing or duration of preventive anticoagulant treatment.
  • It was a single-institution experience, so results may differ elsewhere.
  • Two patients who died of sudden cardiac death had no autopsy, so pulmonary embolism may have been undercounted.
  • Ultrasounds may have given false-negative results, and patients discharged earlier had fewer surveillance studies, so deep vein thrombosis may have been undercounted.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Mesothelioma.

Related studies

• Commentary: Focused attention on proactive identification of deep venous thrombosis after pleurectomy/decortication for malignant pleural mesothelioma — S.S. Groth, R.T. Ripley, et al. (2020)
• Thromboembolic Events in Malignant Pleural Mesothelioma — D. Koksal, O. Safak, et al. (2016)
• Commentary: Mesothelioma: The Guinness world record holder in thromboembolism — R.B. Cameron (2020)
• Quality of life after radical pleurectomy decortication for malignant pleural mesothelioma — N.M. Mollberg, Y. Vigneswaran, et al. (2012)
• Commentary: To scan or not to scan: No longer the question for mesothelioma patients after pleurectomy — E.A. David, S.M. Atay (2020)
• Is pleurectomy and decortication superior to palliative care in the treatment of malignant pleural mesothelioma? — I. Zahid, S. Sharif, et al. (2011)

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