Conclusions Results Methods Background Venous thrombo-embolism in patients undergoing neo- adjuvant chemotherapy and surgery for oesophago-gastric cancer. M Khine, T Asghar, A Crumley, C Craig, G Fullaton, CK McKay, M Forshaw, Glasgow Royal Infirmary 1.Heit JA, Silverstein MD, Mohr DN et al. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med 2000;160:809 –15. 2.Starling N, Rao S, Cunningham D et al. Thromboembolism in patients with advanced gastroesophageal cancer treated with anthracycline, platinum, and fluoropyrimidine combination chemotherapy: a report from the UK National Cancer Research Institute Upper Gastrointestinal Clinical Studies Group. J Clin Oncol 2009;27:3786 –93 3.Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med May 22;336(21): Teman NR, Silski L, Zhao L et al. Thromboembolic events before esophagectomy for esophageal cancer do not result in worse outcomes. Ann Thorac Surg 2012;94:1118–25 5.Baglin TP, Brush J, Streiff M. Guidelines on use of vena cava filters. British Committee for Standards in Haematology. Brit J Haematol. 2006, 134, 590–595 6.Kearon C, Akl EA, Comerota AJ et al. Antithrombotic therapy for VTE disease: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141(2 suppl):e419-94S The relationship between cancer, chemotherapy, surgery and venous thrombo-embolism (VTE) is well established 1. Since the adoption of neo-adjuvant chemotherapy prior to oesophago- gastric resection, the development of VTE during chemotherapy, has been described 2. There is also evidence to suggest that low molecular weight heparin (LMWH) reduces the VTE risk in ambulatory patients with cancer, receiving chemotherapy 3. Despite this, no guidelines exist for the prevention or management, of VTE complications in pre-operative patients receiving neo-adjuvant chemotherapy for oesophago-gastric cancer. The aim of the study was to investigate the incidence and management of VTE in patients undergoing neo-adjuvant chemotherapy and surgery, for oesophago-gastric cancer, in a regional unit. Data for all patients undergoing resection in the Upper GI unit, Glasgow Royal Infirmary, was prospectively recorded in a database. Database and case note review of consecutive patients undergoing neo-adjuvant chemotherapy and surgery, over a three and a half year period, was performed. All 15 patients received treatment with LMWH and an inferior vena cava (IVC) filter. LMWH was discontinued after 6 months in 7 patients, after 9 months in 1 patient and stopped on discharge in 1 patient. In 3 patients, LMWH was switched to warfarin. In 2 patients the duration of treatment was not recorded. Filter retrieval was attempted in 7 patients and successfully retrieved in 4, with one patient dying of pulmonary embolism during attempted retrieval. Thrombo-embolic events are a significant source of morbidity and need for intervention, in patients undergoing neo-adjuvant chemotherapy and surgery, for oesophago-gastric cancer. We are in need of a consensus/ guidelines on the management of the condition. The role of prophylactic treatment with LMWH during neo-adjuvant chemotherapy should also be considered Although the absolute number of patients with VTE in our cohort is small, the rate (10%) is clinically significant and consistent with other studies : 11% with Starling et al 2 and 14% with Teman et al 4. Furthermore, we may have underestimated the true rate of VTE, as patients who did not proceed to surgery following chemotherapy, were not included in the study and the diagnosis of VTE was made on routine portal venous CT scanning and not dedicated CTPA. During the first 3 months after VTE, the risk of recurrence in the absence of anticoagulation is about 50%, 40% during the first month and 10% during the subsequent 2 months 3. Insertion of Vena cava filters is recommended by British Committee for Standards in Haematology in any preoperative patient with recent VTE (within 1 month) in whom anticoagulation must be interrupted. (Grade C, level IV) 5. Optimal treatment duration with LMWH is not known. Most patients with pulmonary embolism associated with a reversible provoking risk factor, such as surgery or chemotherapy, should stop treatment after three months because of the low risk of recurrence 6. Discussion Upper GI Unit, Glasgow Royal Infirmary, Prospective Database 155 patients had major resection after neoadjuvant chemotherapy from March 2009 to December on post neoadjuvant chemotherapy developed major venous thromboembolism on CT (10%) All 15 patients had treatment with IVC filter and LMWH 15 IVC filters inserted over 3 years Successfully Retrieved (n=4) Not Retrieved (n=11) Attempted but failed (n=2) Massive PE and Death during retrieval (n=1) Embedded/ migrated on CT (n=3) Early postoperative death (n=1) Not retrieved, no reason found (n=4) Treatment with anticoagulation (n=15) LMWH stopped on d/c (n=1)Switched to Warfarin (n=2)LMWH for 6 months (n=7)LMWH for 9 months (n=1) Suboptimal dose (2,500 u), developed further symptomatic PE (n=1) On LMWH but died at 2 months (n=1)LMWH for unknown duration (n=2) 155 patients underwent surgery, following neo-adjuvant chemotherapy from March 2009 to December Major VTE complications were noted in15 patients (10%) on routine CT assessment following chemotherapy; Pulmonary embolism in 14 patients and ileo-femoral thrombosis in 1 patient.. 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