GSOR06 Presentation Time: 5:25 PM

Purpose

Patients on chronic anticoagulation (AC) represent a challenge for operative, gynecologic (gyn), intracavitary (IC) and interstitial (IS) brachytherapy (brachy). Frequently, AC is temporarily held to permit use of epidural catheters for anesthesia and pain control, and to minimize the risk of bleeding during applicator insertion and removal. This is complicated by significant risks of thromboembolism during brachy related to patient immobilization, surgery, cancer diagnosis, and comorbidities. There are currently no guidelines for AC management in patients undergoing operative gyn brachy. Thus, the aim of this study is to evaluate the safety and efficacy of our practice approach to patients with thromboembolic disease on chronic AC, undergoing operative brachy for gyn malignancies.

Materials and Methods

After IRB approval, we reviewed the records of 277 patients consecutively treated from 2013 to 2022 with operative brachy for gyn malignancies to identify 30 patients who had perioperative or chronic thromboembolic disease requiring AC therapy. We determined indications for AC use, operative metrics, oncologic and brachy characteristics, duration of AC interruption, as well as operative or postoperative complications. The primary aim was to determine operative or postoperative (within 90 days) embolic or hemorrhagic complications as measured by the Common Terminology Criteria for Adverse Events (CTCAE).

Results

The median age was 66 (range 35-80) years and patients were treated for cervical (n=14), inoperable uterine (n=11), recurrent uterine (n=2), and vaginal (n=3) cancers. Median follow up was 9 (range, 0-70) months after brachy. Indications for AC therapy were DVT (n=13), pulmonary embolism (n=8), and atrial fibrillation/flutter (n=11). AC medications used were apixaban (n=17), enoxaparin (n=5), rivaroxaban (n=3), warfarin (n=2), and intravenous heparin (n=3). Implants were IC (n=14), IS (n=7) and combined IC/IS (n=9), with a median number of 2 (range, 1-3) implants per patient and 4 (range, 2-9) brachy fractions. 16 patients received epidurals prior to the operative procedure. 26 patients were on AC prior to brachy and 4 started in the perioperative period. Therapeutic AC was held in 24 patients prior to operative brachy. The median total duration of AC Interruption was 2 (range, 0-16) days before and 1 (range, 0-4) days after the operative procedure, with median total duration of AC interruption 4 days. DVT prophylaxis was used after applicator placement in most patients, which included: IVC filter (n=3), subcutaneous heparin (n=15), intravenous heparin (n=1), prophylactic dose enoxaparin (n= 5), therapeutic dose enoxaparin (n=2). The median days of bedrest immobilization was 1 (range, 1-8) per implant. Only 3 patients (10%) experienced CTCAE grade≥ 2 operative or postoperative complications with no grade 4 or 5 events. One patient developed postoperative grade 2 vaginal bleeding treated outpatient with megace. A second patient developed grade 3 vaginal bleeding operatively in the setting of severe thrombocytopenia and required blood transfusion and vaginal packing. The third patient experienced grade 2 atrial fibrillation after two fractions which requiring immediate resumption of AC and inpatient admission.

Conclusions

We observed a low and acceptable rate of grade≥ 2 operative or postoperative embolic or hemorrhagic complications in our cohort. IC and IS operative brachy with frequent use of epidural catheters and bedrest appear safe in patients with perioperative or chronic thromboembolic disease on AC.