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Notable Variation Exists in the Treatment of Serious VTE Events in Pediatric Leukemia

Notable Variation Exists in the Treatment of Serious VTE Events in Pediatric Leukemia

Among hematology, oncology, and bone marrow transplant practitioners, notable variations in practice regarding the treatment of serious venous thromboembolism (VTE) events, pulmonary embolism (PE), and cerebral venous sinus thrombosis (CVST), were noted in children with leukemia, according to survey results presented at the Thrombosis & Hemostasis Summit of North America (THSNA) 2020 Virtual Conference.

The findings were presented by Melanie Degliuomini, MD, of the Weill Cornell Medicine Department of Pediatrics in New York, New York, and colleagues.

“VTE is a known complication in pediatric leukemia patients; severe events, such as PE, and CVST are unfortunately known to occur,” said Dr. Degliuomini. “Management guidelines are currently lacking with the majority of treatment guidance coming from adult literature and noncancer-specific pediatric literature.”

The investigators questioned, “How are physicians managing PE and CVST in children with leukemia?”

To gain insight into common practices, the team performed an anonymous cross-sectional survey of pediatric hematology or pediatric hematology/oncology members of the American Society of Hematology (ASH), and the pediatric subcommittee of VTE Network of the Hemostasis & Thrombosis Research Society (VENUS) using an online survey tool (Qualtrics). Survey questions covered 2 primary areas for both PE and CVST: the duration of therapy and repeat imaging.

The investigators sent 870 surveys and achieved a response rate of 17.7% (154/870). After excluding 12 surveys based on predetermined exclusion criteria, 142 surveys were included in the final analysis. Of the respondents, 52% were from hematology practices and 13% were from oncology practices, while 28% were from combined practices and 7% specialized in bone marrow transplant.

Regarding the duration of therapy for PE (133 responses), 40% of respondents reported treatment for 6 months, while 29% reported treatment for 3 months, and 10% reported treatment until the end of asparaginase therapy. However, some physicians reported treating PE until the end of cancer treatment or until central venous catheter removal.

Concerning repeat imaging of PE (131 responses), most respondents performed repeat imaging prior to stopping anticoagulation (66%). Of the respondents who performed repeat imaging (85 respondents), 39%, 41%, and 13% reported reimaging at 6 weeks, 3 months, and 6 months, respectively. Approximately half of the respondents (51%) required complete PE resolution before stopping anticoagulation.

Concerning the duration of therapy for CVST (131 respondents), 40% treated patients for 3 months, while 24% treated patients for 6 months and 15% treated patients until the end of asparaginase therapy.  A large majority of respondents (95%) repeated imaging of CVST before stopping anticoagulation and of those (122 respondents), 39%, 50%, and 3% repeat CVST imaging at 6 weeks, 3 months, and 6 months, respectively. Only 39% required complete CVST resolution prior to stopping anticoagulation.  

Limitations of the study included the low response rate and unanswered questions on some surveys.

“[T]here is notable variation in the management of PE and CVST in children with leukemia, including treatment duration and use of imaging,” concluded Dr. Degliuomini. “The development of prospective studies focused on the management of these high-risk clots in pediatric cancer patients is crucial to driving the development of standard guidelines for the pediatric hematology-oncology community.”

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