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Coagulation Derangements in Oral and Maxillofacial Surgery in Patients with a Documented Cancer: a Follow-up Study after Surgery
1 Faculty of Medicine and Surgery, Oral and Maxillofacial Institute, Correspondence: * corresponding author, giuseppe.colella{at}unina2.it TO THE EDITOR: Hypercoagulability is normally due to derangements in the blood coagulation cascade, both genetic and acquired, which may predispose to abnormal clotting activation or deficiency in natural inhibitors’ control (Furie and Furie, 1992; Miletich et al., 1993; Dahlback, 1994; Schaper, 1994; Ames et al., 1995). Thrombophilia is usually caused by aberrant coagulation and by cell activation, but it is also related to such specific factors as oral contraceptives, pregnancy, puerperium, trauma, prolonged immobilization, cancer, and surgery (Malm et al., 1992; Di Micco et al., 2002). Therefore, the risk of thrombosis is increased by abnormalities of coagulation cascade, natural clotting inhibitors, and fibrinolysis derangements. Our study examined the strength of the association between risk factors for thrombosis and maxillofacial surgery (MFS) in cancer patients. Thus, the aim of our study was to determine the mechanism by which cancer could cause or favor the development of a thrombo-embolic state in patients who had undergone surgery. Therefore, to determine the incidence of these prothrombotic abnormalities in MFS, we enrolled 15 patients with a documented diagnosis of cancer and 30 healthy subjects, blood donors at our university matched for sex, age, body mass index, height, and social background. The protocol was approved by an Institutional Review Board, and patients gave informed consent. Plasma samples for determination of PT, APTT, Fibrinogen (Fg), coagulation Factors (II, VII, VIII, IX, X, XI, XII), coagulation inhibitors (ATIII, PC, PS, and APC resistance), fibrinolysis (PLG, t-PA, PAI-1), antiphospholipid antibodies (ACA beta 2GPI IgG and IgM, Lupus Anticoagulant), and activation peptides (D-Dimers and prothrombin fragment 1+2/F1+2) assays were drawn immediately after entry and then daily one day before and two days after surgery. All parameters were carried out according to International Laboratory Techniques. Normal plasma levels for PT, APTT, natural clotting inhibitors, and coagulation factors II, V, VII, IX, X, XI, XII were documented in all patients. During the observational surgery period, no changes in all of these parameters were observed. High basal values of Fg, PAI-1, F VIII, F1+2, and D-dimers were found in all patients compared with healthy subjects (326 ± 46 mg/dL, 50 ± 24 ng/mL, 110 ± 37%, 1.18 ± 0.9 nM and 275 ± 125 ng/mL vs. 265 ± 114 mg/dL, 25 ± 17.5 ng/mL, 85 ± 24.5%, 0.40 ± 0.35 nM and 175 ± 145 ng/mL, respectively, p < 0.001; Mann Whitney U-test). The plasma levels rapidly increased before surgery (348 ± 55 mg/dL, 62 ± 37 ng/mL, 116 ± 33%, 2.9 ± 1.4 nM and 355 ± 105 ng/mL, respectively; p < 0.001; Fisher Exact Test), reaching the highest values after surgery (417 ± 117 mg/dL, 75 ± 41 ng/mL, 125 ± 31%, 2.95 ± 1.8 nM and 455 ± 90.5 ng/mL, respectively; p < 0.001; Fisher Exact Test). Moderate titers of IgG anticardiolipin antibodies b2-glycoprotein type I (> 10.5 IU/mL, cut-off point of 6.0 in our general population) were found in eight out of 15 patients. In agreement with other authors, analysis of our data suggests a state of hypercoagulability in cancer disease associated with maxillofacial surgery. The significant increase of plasma fibrinogen levels and the activation peptides (F1+2 and D-dimers) show a hypercoagulability state in this setting associated with endothelial cell activation and dysfunction (PAI-1 and F VIII), with thrombin formation and fibrin deposition (F1+2 and D-dimers). Therefore, analysis of our data also demonstrates a hypercoagulable state during the follow-up period of maxillofacial surgery associated with cancer disease (Lowry, 1995). Our report gave considerable information on the clinical situation when surgeons cause patients to become thrombophilic by removing their cancer. The mechanism that causes these coagulation derangements is still unknown; however, it is extremely complex and is partly related to coagulation alterations found in our patients. A better understanding of these mechanisms will help to prevent thrombo-embolic complications. The authors believe that it is mandatory to study coagulation cascade, fibrinolysis, and endothelial cell activation to prevent thrombotic events before OMF surgery. REFERENCES
Journal of Dental Research, Vol. 82, No. 11,
864-865 (2003)
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