The balance of risk of bleeding and thrombosis in melanoma patients with brain metastases

I read with interest the study by Alvarado et al. on the ‘Risk of intracranial hemorrhage with anticoagulation therapy in melanoma patients with brain metastases’ 1. The authors performed a retrospective review, at a single cancer center, of patients with melanoma with venous thromboembolism (VTE) with evidence of brain metastasis at the time of diagnosis of VTE. The occurrence of intracranial hemorrhage with anticoagulation was low at 4% and was not statistically different from the lack of such hemorrhage among the small group of 17 patients without anticoagulation. The decision to anticoagulate in this setting is trying to balance the risk of thrombosis and hemorrhage. The study does not report occurrence of subsequent VTE events, VTE hospitalization or pulmonary embolism, only of survival as the ultimate measure of balance of risks. If the rate of VTE complications without anticoagulation is low or VTE occur despite anticoagulation, the observed 4% intracranial hemorrhage rate with anticoagulation rate might still be deemed high. Inferior vena cava filter placement alone might be a reasonable risk–benefit balance. The ascertainment of further VTE events may be difficult in a retrospective study. But I hope the authors can address the thrombotic risks without anticoagulation, either from this study population or those expected from the literature. Acknowledgements Conflicts of interest There are no conflicts of interest.