Primary Thromboprophylaxis - PowerPoint Presentation

Slide1

Primary Thromboprophylaxis for Cancer Outpatients on Chemotherapy: Case study

Carme Font, MDMedical Oncology DepartmentBarcelonaSpain

Slide2

Primary Thromboprophylaxis in Cancer

Slide3

Primary Thromboprophylaxis in Cancer Khorana et al. Cancer 2013

Slide4

Emergency Room2nd October

, 201568-yr-old male Acute-onset

severe

diffuse abdominal cramping

pain

with

heavy

bilious

vomiting

Practising

Stomatologist

.

Active

smoker

. Overweight: 1,73 m 93 Kg BMI 31 Kg/m2Arterial hypertension -> EnalaprilDiabetes Mellitus -> Metformin Chronic constipation.

Slide5

Emergency Room2nd October

, 201568-yr-old male Acute-onset

severe

diffuse abdominal cramping

pain

with

heavy

bilious

vomiting

Practising

Stomatologist

.

Active

smoker

. Overweight: 1,73 m 93 Kg BMI 31 Kg/m2Arterial hypertension -> EnalaprilDiabetes Mellitus -> Metformin Chronic constipation.

Slide6

Emergency Room2nd October

, 201568-yr-old male Acute-onset

severe

diffuse abdominal cramping

pain

with

heavy

bilious

vomiting

Blood

test:

15.6 gr/dl

Hemoglobin

8,820

Leukocytes/mm3 264,000 Platelets/mm3Liver and renal parameters within normal limits Abdominal X-ray:Abnormal air-fluid levels in dilated small bowel loops compatible with intestinal occlusion.

Slide7

Emergency Room2nd October, 2015

Emergency abdominal CT scan:

3 x 3.5 cm

transmural

infiltrative

mass

compatible

with

occlusive

neoplasia

in

the

middle

third

of

the descending colon.Distension of ileal loops and the ascending, transverse and upper third of descending colon. No signs of dissemination to the liver, other abdominal structures including lymph nodes. Permeable portal vein. Infrarenal partially thrombosed aortic aneurysm of 29 mm in the right common illiac artery (35 mm length). In the partially explored

lung parenchyma, a 14 mm paracardiac nodule

was

observed

in

the

middle

lobe

suggestive

of metastatic lesion in the context of the patient.

Slide8

Hospital Admission -> 3rd October, 2015

Emergency Fibrocolonoscopy -> Descending Colon StentingBridge-to

-Surgery

- To

avoid

emergency

surgery

-

Allow

preoperative

bowel

preparation

Colono-CT scan: no concomitant lesions in the rest of the colon.7th October, 2015Elective left laparoscopic-assisted

hemicolectomy.No

signs

of peritoneal

involvement

.

Postoperative

fever

->

Prolongued

IV

antibiotics

-> 16

days

of

hospitalization

After hospital

discharge

:

Overall

Oral

antibiotics

+

Enoxaparin

40mg/

day

for

10

days

-> 26

days

LMWH

prophylaxis

Home

nursing

support

for

7

days

24-hour

ER

visit

for

caring

for

the

surgical

wound

.

Slide9

Hospital Admission -> 3rd October, 2015

Emergency Fibrocolonoscopy -> Descending Colon StentingBridge-to

-Surgery

- To

avoid

emergency

surgery

-

Allow

preoperative

bowel

preparation

Colono-CT scan: no concomitant lesions in the rest of the colon.7th October, 2015Elective left laparoscopic-assisted

hemicolectomy.No

signs

of peritoneal

involvement

.

Postoperative

fever

->

Prolongued

IV

antibiotics

-> 16

days

of

hospitalization

After hospital

discharge

:

Overall

Oral

antibiotics + Enoxaparin 40mg/day for 10 days -> 26 days LMWH prophylaxisHome nursing support for 7 days24-hour ER visit for caring for the surgical wound.

The

aneurysmatic

aorta and

the

cardiovascular

risk

factors

were

put

into

the

background

but

not

specifically

addressed

at hospital

discharge

.

Slide10

Medical Oncology Outpatient Clinics First visit

13th, November 2015

Good general

condition

ECOG 0

1,73 m 87 Kg

BMI 29 Kg/m2

Hb

12.5 gr/dl

Leukocytes

6,530

Platelets

235,000

Glucose

130 mg/dl

Final

pathological

Report

:4 cm Adenocarcinoma colonic origin (splenic angle)High

histological grade / Angiolymphatic and perineural invasion

Free

surgical

margins

pT3 N1b (2/16) Mx (

undetermined

lung

nodule

vs.

oligometastasis

)

Discussion

with

the

patient

and

his wife: - Pros and cons of ‘complementary’ chemotherapy. - PET scan - Port-a-cath

Slide11

2nd December, 2015Port-a-cath right subclavian vein PET-scan: confirmed

moderate activity of the paracardiac nodule.

17th December

, 2015

Chemotherapy

mFOLFOX-6

scheduled

by

telephone

call

Continuous

5-FU

infusion

for

3

days at home 26th January, 2016 Pre-C4 FOLFOXAsthenia G2 ECOG1Paresthesia in the hands G1 4-day history of edema on the left legHemoglobin 11,5 gr/dl CT scan 18th

January 2016 (3 cycles Folfox):

Leukocytes

4,500/mm3

Reduction

paracardiac

nodule

to

12 mm (

prev

14 mm)

Platelets

80,000 No other

signs

of

cancer

dissemination

.

Glucose

350 mg/dl Infrarrenal aneurysmatic aorta 35 mm (prev 29 mm) involving the right and left common illiac arteries.  Chemotherapy postponed  Day

Care

Hospital

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DAY CARE HOSPITAL: Supportive Care in Cancer Multidimensional approach

PHYSICAL NEEDSUS-Doppler-> Femoral and

popliteal DVT -> self-injection LMWH

Insulin during

chemotherapy

Close

p

latelet

count

monitoring

Referral

to

a

cardiovascular

specialist

EDUCATION: Awareness about PE symptomsTo prevent posthrombotic syndromeTo promote regular physical activity

EMOTIONAL

NEEDS

Knowledge

crisis: Stress and

concern

for

becoming

aware

of

the

multiple potentially ‘life-threatening

’

complications

:

- VTE

-

Aneurysmatic

aorta

-

Paracardiac noduleFear about receiving more chemotherapy (asthenia, parestesia, VTE) SOCIAL NEEDSUncertainty about his future professional practice as stomatologistConcern about how to drive his commitment with other professionals hired in his clinics.

Slide13

May 2016: completed 11 cycles FOLFOX (Dose reduction) June 2016: CT scan

stability of the paracardiac

nodule

July

2016:

Cancer

Committee

Paracardiac

nodule

not

accesible

for

radical

treatment

with radiofrequency August 2016 -> Medial lobe segmentectomy with minimally invasive videothoracoscopy.

Final pathological diagnosis: Hamartoma.

October

2016

CT

scan

:

No

signs

of tumoral

activity

.

Persistent

infrarrenal

aneurysmatic

aorta 35 mm

with

greater

involvement

of

both primitive illiac arteries with minimal mural thrombus. Anticoagulant LMWH interrupted after 9 months -> ASA 100 mg/dayDecember 2016 Aortic bifurcated prosthesis placed.June 2017 No evidence of cancer relapseMild peripheral neuropathy, still works part-timeMinimal posthrombotic symptoms

in

the

left

leg

Quit

smoking

Regular

physical

activity

97 Kg BMI 32 Kg/m2

The

ongoing

patient’s

journey

…

Slide14

Could it have been done better to prevent VTE in this patient

?

Slide15

4.2.1. In outpatients with cancer who have no additional risk factors for VTE,

we suggest against routine prophylaxis with LMWH or LDUH (

Grade 2B

) and recommend

against

the

prophylactic

use

of

vitamin

K

antagonists

(

Grade

1B

) .

4.2.2. In outpatients with solid tumors who have additional risk factors for VTE and who are at low risk of bleeding, we suggest prophylactic dose LMWH or LDUH over no prophylaxis.

4.4. In outpatients

with

cancer

and

indwelling

central

venous

catheters

,

we

suggest

against

routine

prophylaxis

with

LMWH or LDUH (

Grade

2B) and suggest against the prophylactic use of vitamin K antagonists (Grade 2C).Additional risk factors include: previous venous thrombosis, immobilization, hormonal therapy, angiogenesis inhibitors, thalidomide, and lenalidomide.

5.4 American

College

of

Chest

Physicians

(ACCP)

Guidelines

2012

Cancer

outpatients

thromboprophylaxis

Slide16

4.2.1. In outpatients with cancer who have no additional risk factors for VTE, we

suggest against routine prophylaxis with LMWH or LDUH (Grade 2B

) and recommend

against

the

prophylactic

use

of

vitamin

K

antagonists

(

Grade

1B

) .

4.2.2.

In

outpatients with solid tumors who have additional risk factors for VTE and who are at low risk of bleeding, we suggest prophylactic dose LMWH or LDUH over no

prophylaxis.4.4. In outpatients

with

cancer

and

indwelling

central

venous

catheters

,

we

suggest

against

routine

prophylaxis

with

LMWH or LDUH (

Grade 2B) and suggest against the prophylactic use of vitamin K antagonists (Grade 2C).Additional risk factors include: previous venous thrombosis, immobilization, hormonal therapy, angiogenesis inhibitors, thalidomide, and lenalidomide.

Chemotherapy

not

included

!!!

American

College

of

Chest

Physicians

(ACCP)

Guidelines

2012

Cancer

outpatients

thromboprophylaxis

Slide17

PROTECHT

Need to treat 53 patients

to

avoid 1 arterial

or

venous

thrombotic

event

SAVE-ONCO

Need

to

treat

45

patients to avoid 1 venous thrombotic event NO differences in mortality

Slide18

PROTECHT

Need to

treat

53 patients

to

avoid

1 arterial

or

venous

thrombotic

event

SAVE-ONCO

Need

to treat 45 patients to avoid 1 venous thrombotic event NO differences in mortality

Slide19

PROTECHT

Need to

treat

53 patients

to

avoid

1 arterial

or

venous

thrombotic

event

SAVE-ONCO

Need

to treat 45 patients to avoid 1 venous thrombotic event NO differences in mortality

Slide20

Cancer-Associated Thrombosis: risk

factors

Slide21

N= 17,984

Slide22

Slide23

Slide24

Ingrid Pabinger Cihan Ay

Alok Khorana

Risk-assessment

models

developed

to

predict

VTE in

cancer

patients

Slide25

May - June 2017

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Slide27

Slide28

Score > 2 12-mo probability 33.9%Score = 2 12-mo probability 19.4%

Score = 1 12-mo probability 9.7%Score = 0 12-mo probability

3.7%

Slide29

Conclusions:PHARMACOLOGICAL thromboprophylaxis? Several risk-assessment models to identify cancer at a highest VTE risk. Lack of controlled

trials evaluating the efficacy and safety of primary thromboprophylaxis based upon these models. Lack of risk assessment models

to predict

bleeding (chemo-induced

renal

insufficiency

and

thrombocytopenia

).

Several

Cancer

-,

Treatment

- and

Patient-related

VTE-

risk

factors -> Continuous reassessment and Shared-decision making with patients / caregivers.EDUCATION: To increase AWARENESS amongst Health Professionals and Patients. Early diagnosis of VTE.VTE prevention: promoting Healthy Lifestyles.

Slide30

Thank you ! CFONT@clinic.cat