Malignancy and hemostasis

Abstract

The presence of cancer may predispose the patient to a hypercoagulable state. Approximately 15% of all patients with a malignancy may be affected by some form of thromboembolic disease. Trousseau's syndrome relates to this predisposition to both arterial and venous coagulation in this cohort of patients. This well-documented state affects the local tumor site as well as causes these systemic effects. The additional burden on the patient of potential immobility, chemotherapy, surgery, indwelling lines, and nutritional deficit make thromboembolic disease more prevalent. It must also be borne in mind that malignant disease may also result in a greater bleeding tendency due to dysfunction with components of the coagulation cascade. Additionally, many patients may be on anticoagulant therapy, and bone marrow disorders such as leukemia may cause thrombo-hemorrhagic complications. The oral surgical management of cancer patients in regard to hemostasis is a complex interplay of history, physical findings, laboratory values, and provider preference. There is limited high-quality information available regarding the specific oral surgery population, and therefore the best recommendations are extrapolated from available studies and guidelines in the medical and surgical literature. The ultimate decision is at the discretion of the treating provider to ensure procedures are executed appropriately, and there is a plan for monitoring in the postoperative period. Certainly the patient and treatment factors which place patients at greater risk for bleeding should be evaluated together in consultation with the patient's oncologist prior to surgery. Once the risk of bleeding is established, laboratory testing guides consideration of preoperative transfusion, further medical management, or alteration of the surgical plan to reduce risk of bleeding intraoperatively. Scheduling surgery to accommodate for the expected bone marrow recovery following the drop in the patient's blood counts is also a helpful measure. Reducing the extent of surgery and dividing treatment into multiple visits can decrease the stress on the patient's hemostatic mechanisms. Careful attention to surgical technique to minimize tissue trauma and blood loss is essential, and local hemostatic measures discussed elsewhere are helpful adjuncts.