Incidence and management of venous thromboembolism in patients with glioblastoma: a retrospective single-center analysis

Introduction

Glioblastoma (GBM) is associated with a prothrombotic state, directly associated with the production of the potent procoagulant, tissue factor (TF), significantly increasing the risk of venous thromboembolism (VTE). The risk of intracranial hemorrhage with the use of anticoagulants complicates the management of VTE in patients with brain tumor. These complications pose a challenge in clinical management, balancing the risk of hemorrhage with the need for anticoagulation or mechanical filtration. Furthermore, this group of tumors is usually excluded from most studies.

Purpose

To evaluate the incidence, distribution, therapeutic management, and timing of thrombotic events in a large cohort of patients with glioblastoma treated at a specialized neurological center in a South American country.

Methods

We conducted a retrospective descriptive study of 641 patients diagnosed with glioblastoma. Patients were categorized based on the presence and type of thrombotic event: no thrombosis, infrapatellar deep vein thrombosis (DVT), suprapatellar DVT, pulmonary embolism (PE), and cerebral venous thrombosis (CVT)/other. Treatment modalities and the mean time from the first surgery to the thrombotic event were analyzed.

Results

Out of 641 patients, 448 (69.9%) did not experience thrombotic events. Thrombosis occurred in 193 patients (30.1%), with a mean time from surgery to event of 162 days. Enoxaparin was the primary treatment (71.5%), followed by inferior vena cava (IVC) filters (23.3%).

Events were distributed as follows:

Infrapatellar DVT: 90 patients (14.0%). Management: enoxaparin (n=66, 73.3%), IVC filter (n=21, 23.3%), others (n=3). Mean time to event: 98 days.

Suprapatellar DVT: 40 patients (6.2%). Management: enoxaparin (n=25, 62.5%), IVC filter (n=14, 35.0%), acenocoumarol (n=1). Mean time to event: 270 days.

Pulmonary Embolism: 56 patients (8.7%). Management: enoxaparin (n=43, 76.8%), IVC filter (n=10, 17.9%), thrombectomy (n=2), surveillance (n=1). Mean time to event: 184 days.

CVT/Other: 7 patients (1.1%). Management: enoxaparin (n=4), surveillance (n=1), TBD (n=2). Mean time to event: 192 days.

Conclusions

The incidence of VTE in this GBM population was approximately 30%. Distal (infrapatellar) DVT was the most frequent presentation and occurred earliest (mean 98 days), whereas proximal DVT occurred significantly later (mean 270 days). While low molecular weight heparin was the standard of care, nearly a quarter of thrombotic patients required IVC filters. Given the high incidence of thrombosis in this subpopulation, further studies are warranted to identify patients at highest risk and to define whether prophylactic strategies offer a benefit that outweighs the known risk of bleeding.Table 1  Graphic 1