University of Virginia CHARLOTTESVILLE, Virginia, United States
Background/Case Studies: Malignancy affects coagulation, increasing the risk for both thrombosis and hemorrhage.1 Tumor cells promote thrombosis by releasing tissue factor and procoagulant vesicles, while also releasing substances like heparinase and cancer procoagulant that activate clotting factors.2-4 There are minimal data describing perioperative enzymatic coagulation and thrombin generation (TG) in patients having gynecologic surgery for malignancy. Our study aimed to explore perioperative TG profiles in patients having gynecologic surgery for benign and malignant pathologies. We hypothesized that patients having surgery for malignancy would demonstrate a more procoagulant profile compared to those undergoing similar surgery for benign indications. Further, we hypothesized that patients undergoing surgery for malignancy would have reduced TG six weeks after surgery compared to their baseline cancer state.
Study
Design/Methods: We collected platelet-poor plasma from 13 patients undergoing gynecologic surgery for malignant (n=6) or benign (n=7) pathology. Samples were collected at 4 time points: preoperatively, intraoperatively after tumor resection, postoperative day 1, and at 6-week follow-up. Six normal plasma samples were also analyzed as controls. In vitro TG was assessed using a calibrated automated thrombogram to measure TG lag time, endogenous thrombin potential (ETP), and peak TG. Results were displayed on Box and Whisker plots. The effect of both pathology and time on TG parameters was analyzed using two-way ANOVA and we tested for interaction between pathology and time.
Results/Findings: For lag time there was both a significant effect observed for time (p=0.01) and pathology (p=0.002). For peak TG there was both a significant effect observed for time (p=0.0003) and pathology (p=0.01). For endogenous thrombin potential there was a significant effect observed for time (p< 0.001), but not pathology (p=0.22). A significant interaction effect between time and pathology was only observed for peak TG. The main trends we observed included a longer TG lag time in malignant patients at all time points, higher peak TG in benign patients during surgery, and higher ETP in benign patients during surgery. TG declined in both benign and malignant surgical patients during surgery and returned towards baseline on POD1. Conclusions: Women having gynecologic surgery for malignancy did not demonstrate evidence of hypercoagulability on in vitro TG assessment. In fact, there was relative hypocoagulability compared to patients having surgery for benign pathologies including prolonged TG lag time, and reduced peak TG and lower ETP. Further studies are needed to understand the full perioperative coagulation profile in these patients.
