Management of cancer-related thrombosis in the era of direct oral anticoagulants: A comprehensive review of the 2019 ITAC-CME clinical practice guidelines. On behalf of the Groupe Francophone Thrombose et Cancer (GFTC).

Venous thromboembolism (VTE) is a common disease complication in cancer patients and the second cause of death after cancer progression. VTE management and prophylaxis are critical in cancer patients, but effective therapy can be challenging because these patients are at higher risk of VTE recurrence and bleeding under anticoagulant treatment. Numerous published studies report inconsistent implementation of existing evidence-based clinical practice guidelines (CPG), including underutilization of thromboprophylaxis, and wide variability in clinical practice patterns across different countries and various practitioners. This review aims to summarize the 2019 ITAC-CME evidence-based CPGs for treatment and prophylaxis of cancer-related VTE, which include recommendations on the use of direct oral anticoagulants specifically in cancer patients. The guidelines underscore the gravity of developing VTE in cancer and recommend the best approaches for treating and preventing cancer-associated VTE, while minimizing unnecessary or over-treatment. Greater adherence to the 2019 ITAC guidelines could substantially decrease the burden of VTE and improve survival of cancer patients.

Factors influencing patient's perception of long-term treatment with low-molecular-weight heparins for cancer-associated thrombosis: an updated analysis of TROPIQUE, a prospective observational study.

PURPOSE: Our objective was to compare patient's expectations to their experience and to identify factors predictive of patient's perception of long-term LMWH for the treatment of cancer-associated thrombosis (CAT). METHODS: Results from the validated Perception Anticoagulant Treatment Questionnaires (PACTQ) completed before inclusion (PACTQ1 for expectations) and at the end (PACTQ2 for convenience and satisfaction) of the 6-month TROPIQUE study were studied with principal component analysis. Possible predictive factors of improved perception of LMWH treatment were analyzed with the Kruskall-Wallis test. RESULTS: Among 409 included patients treated with LMWH, 269 PACT-Q1 and 139 PACT-Q2 were evaluable for treatment perception. Patients had high expectations (A1-A7 score of 26.7 ± 3.5, max = 35). Treatment cost (A7 = 1.90 ± 1.31) and concern about a mistake in anticoagulation (A5 = 1.93 ± 1.12) had little importance while LMWH treatment was considered easy to use (A4 = 4.20 ± 0.93). Six-month treatment with LMWH was associated with a high rate of convenience (B1-B11, C1-C2 = 55.1 ± 8.38, max = 65) and a high satisfaction score (D1-D7 = 25.1 ± 4.32, max = 35). Patients' confidence in treatment and perception of possible LMWH side effects were moderate while perception of autonomy and independence significantly improved at the end of the study compared to inclusion. PACT-Q2 satisfaction score was low in patients who experienced bleeding (PACT-Q2 24.1 ± 3.3 vs. 25.1 ± 4.3). LMWH twice daily tended to be found less convenient compared than once daily (53.3 ± 7.2 vs. 55.0 ± 8.3). CONCLUSION: CAT patients had a good perception of the 6-month LMWH treatment when comparing expectations and experience. Using a quantitative scale validated in the general population for VTE and subcutaneous injection and including a large number of patients, bleeding complications and LMWH twice daily were associated with a nonsignificant trend towards a worsen perception.

[Deep venous thrombosis caused by congenital inferior vena cava agenesis]. / Une thrombose veineuse profonde révélant une agénésie de la veine cave inférieure.

Congenital agenesis of the inferior vena cava, although rare, is found preferentially in young patients with proximal deep venous thrombosis. Exact diagnosis can be made thanks to enhanced computed tomography scan and/or magnetic resonance imaging, while Doppler ultrasonography is insufficient to establish an inferior vena cava malformation. A consensus has not yet been established for the treatment but lifelong anticoagulation with elastic stocking support to prevent post-thrombotic syndrome is commonly considered in most cases. We report a case of an unprovoked deep venous thrombosis caused by a congenital agenesis of the inferior vena cava localized to the infrarenal segment, in a 24-year-old man. An anticoagulation with low molecular weight heparin was started and prolonged oral anticoagulation was prescribed. In the absence of the usual thrombotic risk factors, the presence of an inferior vena cava anomaly should be considered.

[Venous thromboembolism and pancreatic cancer]. / Maladie thromboembolique veineuse et cancer du pancréas.

Pancreatic cancer (PC) is a devastating malignancy with an overall 5-year survival of 8% for all stages combined. Most of the PC patients diagnosed have an advanced disease (40%) or metastatic stage (40%), which eliminates surgery as a potentially curative treatment. The disease course is often complicated by venous thromboembolism (VTE) events, which per se account for significant morbidity and mortality, with significantly worsen survival. PC is associated with the highest risk of VTE among all cancer patients. We review the literature data to address the incidence and clinical outcomes of VTE in PC patients. VTE incidence varies from 5 to 41% according to epidemiological studies and is as high as 57% in postmortem series. Since 2013, international clinical practice guidelines recommend primary thromboprophylaxis with a grade 1B level of evidence as an adjuvant therapy in advanced PC. A recent meta-analysis of randomized controlled trials investigating the benefit and risk of low-molecular-weight heparins (LMWH) in ambulatory advanced PC patients under chemotherapy showed that the incidence of VTE was 2.1% in patients treated with LMWH and 11.2% in controls (risk ratio, 0.18; 95% CI, 0.083-0.39; P<0.0001). In conclusion, improved earlier diagnosis and effective management of VTE, a frequent and life-threatening complication in PC, is warranted to improve PC patient outcomes.

[Splenic sarcoidosis diagnosed by US-guided biopsy: About a case]. / Sarcoïdose splénique diagnostiquée par biopsie écho-guidée : à propos d'un cas.

INTRODUCTION: Splenic localisation of sarcoidosis is common but rare as unique location. We report a case diagnosed by US-guided biopsy. OBSERVATION: A 42-year-old woman presented atypic and recidivant epigastric pain. Abdominal ultrasound showed splenic hypoechoic nodules not characterizable with CT or MRI. PET-CT revealed hypermetabolism without any other abnormal metabolic activity. US-guided biopsy with small needle achieved diagnosis of isolated splenic sarcoidosis. CONCLUSION: Diagnosis of splenic nodular sarcoidosis can be challenging without any other localization. Splenic biopsy achieved diagnosis. This procedure is associated with a low risk of complications - in particular hemorragic ones. Diagnostic splenectomy should be an exceptional intervention.

[New international guidelines for curative treatment and prophylaxis for venous thromboembolism (VTE) in cancer patients and the dedicated smartphone application]. / Nouvelles recommandations internationales pour le traitement curatif et prophylactique de la maladie thromboembolique veineuse chez les patients atteints d'un cancer et application dédiée pour smartphone.

Venous thromboembolism (VTE) is a frequent and serious complication in cancer patients, and the second leading cause of death in this setting. Cancer patients are also more likely to present recurrent VTE and major bleeding while taking anticoagulants. Management of VTE in these patients is always challenging and remains suboptimal worldwide. In 2013, the International Initiative on Thrombosis and Cancer (ITAC-CME) released international guidelines for the treatment and prophylaxis of VTE and central venous catheter-associated thrombosis, based on a systematic review of the literature ranked according to the Grading of Recommendations Assessment, Development, and Evaluation scale. An update of these ITAC-CME consensus guidelines, including the use of direct oral anticoagulants, was recently published. In this review, we summarize these updated guidelines. Better adherence to the international guidelines, involving an adequate educational and active implementation strategies, will substantially decrease the burden of VTE and allow to increase survival in cancer patients.

Major bleeding complications in patients treated with direct oral anticoagulants: One-year observational study in a Paris Hospital.

Direct oral anticoagulants (DAOC) are indicated for the treatment of venous thromboembolism and the prevention of stroke or systemic embolism in patients with non-valvular atrial fibrillation. Given their advantages and friendly use for patient, the prescription of long term DOAC therapy has rapidly increased both as first line treatment while initiating anticoagulation and as a substitute to vitamins K antagonist (VKA) in poorly controlled patients. However, DOAC therapy can also be associated with significant bleeding complications, and in the absence of specific antidote at disposal, treatment of serious hemorrhagic complications under DOAC remains complex. We report and discuss herein five cases of major hemorrhagic complications under DOAC, which were reported to the pharmacological surveillance department over one year at Saint-Louis University Hospital (Paris, France). We further discuss the need for careful assessment of the risk/benefit ratio at time of starting DOAC therapy in daily clinical practice.

Autologous hematopoietic stem cell transplantation reverses skin fibrosis but does not change skin vessel density in patients with systemic sclerosis.

Hematopoetic stem cell transplantation (HSCT) improves survival in patients with severe systemic sclerosis (SSc) by resetting the immune system. We studied how HSCT acts on the key SSc skin pathology findings (fibrosis and vascularization). In mean, 3 skin punch biopsies per patient (range 2-6) were analyzed from 13 patients (5 females) with severe diffuse SSc before and up to 96 months after HSCT. Fibrosis of the four skin layers was graded semi-quantitatively and an overall fibrosis score was then calculated. Vessel numbers and calibers were assessed in the superficial and deeper dermis after immune-staining for endothelial antigens (CD31, VE-cadherin and vWF). The median age of patients at HSCT was 47 (24-64) years. The overall median modified Rodnan skin score decreased from 24 to 10 (P=0.003) at first follow-up within a median of 9 (6-36) months after HSCT as did the histological skin score (P=0.03). The modified Rodnan skin score and the fibrosis score correlated positively (r=0.589, P<0.001). The vessels density did not significantly change after HSCT nor did the expression of the tested endothelial markers. Although improving skin fibrosis in patients with SSc, HSCT does not alter vessel density within skin biopsies.

[Autologous stem cell transplantation for autoimmune diseases: recommendations from the SFGM-TC]. / Autogreffe des cellules souches hématopoïétiques dans les maladies auto-immunes : recommandations de la SFGM-TC.

Autologous hematopoietic stem cell transplantation is a valid alternative to immunosuppressive treatment in patients with auto-immune disease; however, the role of this approach remains subject to debate. In the attempt to harmonize clinical practices between different French transplantation centers, the French Society of Bone Marrow Transplantation and Cell Therapies (SFGM-TC) set up its fourth annual series of workshops which brought together practitioners from all of its member centers. These workshops took place in September 2013 in Lille. In this article we give an overview regarding the indications of autologous stem cell transplantation in auto-immune diseases as well as recommendations regarding post-transplant follow-up of patients.

Nephropathie au cours d'une extravasation de produit de contraste iode : quel lien ? a propos d'un cas

Introduction. L'extravasation d'un produit de contraste injecte par voie intraveineuse est rare en pratique clinique courante. Son incidence est relativement faible. Cas clinique. Nous rapportons ici l'observation d'un adulte jeune de 40 ans; obese; qui a la suite d'une extravasation de 50 ml de produit de contraste iode dans l'avant-bras droit; a presente des reactions locoregionales immediates accompagnees d'une insuffisance renale aigue. Un traitement symptomatique institue sur la base d'une rehydratation adaptee a ameliore les signes cliniques apres 48 heures avec secondairement normalisation de la fonction renale. Conclusion. La toxicite des produits de contraste iode est connue et liee a leur osmolarite elevee et a l'importance de la quantite extravasee dans le tissu sous cutane

Nephropathie au cours d'une extravasation de produit de contraste iode : quel lien ? a propos d'un cas

Introduction. L'extravasation d'un produit de contraste injecte par voie intraveineuse est rare en pratique clinique courante. Son incidence est relativement faible. Cas clinique. Nous rapportons ici l'observation d'un adulte jeune de 40 ans; obese; qui a la suite d'une extravasation de 50 ml de produit de contraste iode dans l'avant-bras droit; a presente des reactions locoregionales immediates accompagnees d'une insuffisance renale aigue. Un traitement symptomatique institue sur la base d'une rehydratation adaptee a ameliore les signes cliniques apres 48 heures avec secondairement normalisation de la fonction renale. Conclusion. La toxicite des produits de contraste iode est connue et liee a leur osmolarite elevee et a l'importance de la quantite extravasee dans le tissu sous cutane