INTRODUCTION:Treatment of cancer-associated thrombosis (CAT) requires specific approaches, although it is well codified in most cases. Current national and international (International Initiative on Cancer and Thrombosis, ITAC) Clinical Practice Guidelines (CPG) recommend the use of low-molecular-weight heparin (LMWH) over 6 months as first treatment option, and anticoagulation should be maintained thereafter as long as cancer is active. Since compliance improves when patients understand their disease and related treatments, we created a dedicated patient education program (PEP) for CAT, aiming to improve quality of care.METHODS:Retrospective analysis of all patients who voluntarily joined the PEP for CAT from 2014 to 2020.RESULTS:In total, 182 cancer patients (median age, 64.9 years) were included, 53.3% with metastatic disease. A total of 528 PEP sessions (median, 3 per patient) were delivered. After PEP completion, the rate of self-injections or those performed at home by a relative had increased from 49.1% to 59.8% (P=0.05). Quality of life had improved significantly (P=0.025) and 90.0% of patients reported adhering to anticoagulant therapy.CONCLUSION:Implementation of a structured and personalized PEP for CAT is feasible, allowing to improve cancer patient empowerment, adherence to CAT treatment and quality of life. The Groupe francophone et cancer (GFTC) members aim at facilitating access to CAT-PEP for both patients and caregivers and use of the multi-language ITAC-CPG mobile app (free access: www.itaccme.com) to improve the care and quality of life of patients with CAT.

BACKGROUND:- The management of venous thromboembolism (VTE) is particularly challenging in patients with cancer who undergo complex treatment protocols. Cancer patients often have comorbidities which may affect the efficacy and safety of anticoagulant treatments. Coordinated multidisciplinary management of these complex cases can help optimize delivery of individualized anticoagulant treatment.AIMS:- To describe the multidisciplinary team meeting (MDTM) for the management of VTE in cancer patients at our institution and to document outcomes in these patients.METHODS:- Bi-monthly MDTMs attended by different physicians and nurses were established at Saint-Louis Hospital in 2008. We performed a retrospective analysis of all cases discussed between September 2008 and January 2018.RESULTS:- Over a 10-year period, 520 patients were discussed a total of 551 times. Their mean age was 63 years with 278 (53%) women. The most frequent primary cancer sites were breast (23%), genitourinary (21 %), hematological (20%), digestive (15%), and lung (9%). Fifty-two percent of patients had metastatic cancer, and 54% of them were receiving chemotherapy. The optimal treatment for pulmonary embolism (17%), deep vein thrombosis (16%), catheter-related thrombosis (20%) or combined events (46%) was discussed. Twenty-three patients (4.4%) were discussed for one VTE recurrence and 4 (0.8%) for 2 recurrences.CONCLUSIONS:- A dedicated MDTM for the management of VTE in cancer patients allows to discuss a wide range of clinical scenarios and contributes to optimal adherence to evidence-based clinical practices guidelines. The MDTM evaluation was successfully carried out within a short time-frame of VTE diagnosis and helped optimize individualized treatment plans.

INTRODUCTION:The Coronavirus disease-2019 outbreak (COVID-19) has been declared a pandemic by the World Health Organization. Studies report both a severe inflammatory syndrome and a procoagulant state in severe COVID-19 cases, with an increase of venous thromboembolism, including pulmonary embolism (PE) and deep vein thrombosis (DVT). In this context, we discuss the use of doppler ultrasonography (DUS) in the screening and diagnosis of DVT in ambulatory and hospitalized patients with, or suspected of having, COVID-19, outside the intensive care unit (ICU). MATERIAL AND METHODS:Non-systematic review of the literature. RESULTS:In patients hospitalized for or suspected of COVID-19 infection with the presence of either (a) DVT clinical symptoms, (b) a strong DVT clinical probability (Wells score>2) or (c) elevated D-dimer levels without DVT clinical symptoms and without PE on lung CT angio-scan, DVT should be investigated with DUS. In the presence of PE diagnosed clinically and/or radiologically, additional systematic DVT screening using DUS is not recommended during the COVID-19 pandemic. The use of 4-points compression DUS for DVT screen and diagnosis is the most appropriate method in this context. DISCUSSION:Systematic DUS for DVT screening in asymptomatic COVID patients is not recommended unless the patient is in the ICU. This would increase the risk of unnecessarily exposing medical staff to SARS-CoV-2 and monopolizing limited resources during this period.

Cancer-associated thrombosis (CAT) is the second leading cause of death in cancer patients after tumor progression. The treatment of CAT is challenging because of a high risk of VTE recurrence, a high risk of bleeding, common presence of comorbidities, poly-medication, and potential drug-drug interactions (DDI). Since 2018, direct oral anticoagulants (DOACs) represent a promising therapeutic alternative and have been recently included into the 2019 update of the International Initiative on Thrombosis and Cancer (ITAC-CME) clinical practice guidelines for management of CAT. However, pharmacokinetic studies suggest that concomitant treatment with P-gp or CYP3A4 inhibitors will result in an increased exposure to rivaroxaban and apixaban, but the clinical relevance of these studies is unknown. In addition, there is an important inter-individual variability in drug absorption, distribution, metabolism and elimination, even more in cancer patients. Overall, the risk of pharmacokinetic DDI should be estimated based on several individual (patient age, renal and liver function, number of comedications) and diseases-related factors, including inflammation, sarcopenia, and low body weight. In this context, DDI with clinical implications could be expected with anti-neoplastic agents or supportive care treatments, especially with drugs known to be moderate or strong inhibitors/inducers of CYP3A4 and P-gp. Consequently, in the presence of potential DDIs through CYP3A4, and/or P-gp, LMWHs remain the first-line anticoagulant of choice for the long-term treatment of CAT. Multidisciplinary consultation meetings and therapeutic patient education should be emphasized in the complex management of CAT.

L’épidermolyse bulleuse héréditaire dystrophique récessive (EBDR) est une génodermatose rare caractérisée par une fragilité cutanéo-muqueuse liée à des mutations de COL7A1. L’atteinte est inflammatoire puis fibrosante, se complique d’anémie, dénutrition, sepsis, carcinomes épidermoïdes cutanés. Une voie d’abord, indispensable lors de ces complications, nécessite le plus souvent une pose de cathéter (KT) compte tenu de l’état cutané. L’objectif était de décrire les patients porteurs d’un KT central et/ou périphérique de la cohorte et les caractéristiques cliniques, biologiques des épisodes de thrombose veineuse (TV). Cette étude rétrospective observationnelle incluait les patients portant un KT veineux périphérique ou central suivis pour une EBDR dans un centre de référence adulte entre 2014 et mai 2020. Le critère de jugement principal était la survenue d’une TV sur KT confirmée radiologiquement au cours du suivi. Outre la survenue d’un décès, les paramètres étudiés étaient le contexte clinique (inflammation cutanée, surinfection du KT, dénutrition, carcinome cutané) et biologiques lors de la pose du KT (paramètres usuels d’hémostase et d’inflammation : TP, TCA, fibrinogène, plaquettes, CRP). Une dénutrition sévère était définie par un IMC < 16,6 kg/m2 (1er quartile de la population totale). Au total, ont été inclus 29 KT portés par 10 patients différents. L’âge, le poids et l’IMC médians étaient respectivement 26 ans (± 7), 45 kg (± 12) et 17 kg/m2 (± 3). Quatre patients ont présenté au moins 1 épisode de TV sur KT en cours de traitement pour un sepsis, dont 3 (75 %) présentaient un état cutané inflammatoire, une dénutrition sévère et recevaient une nutrition parentérale sur KT. Les KT étaient des Midline (n = 15), chambre implantable (n = 9), KT centraux (n = 3), Piccline (n = 1) et KT tunnélisé (n = 1) sans différence mise en évidence sur la survenue de TV entre les types. Cinq KT (17 %) se sont compliqués de TV (dont 2 intracardiaques). Celle-ci était significativement associée à l’infection de KT (p < 0,01), un état cutané inflammatoire (p = 0,03), la présence d’une infection (p < 0,01) et d’une bactériémie (p < 0,01) le jour de la pose. Une ferritinémie et un taux de fibrinogène élevés lors de la pose étaient significativement associés à une TV (p = 0,04). Les TV étaient plus fréquentes en cas de dénutrition et nutrition parentérale (non significatif). La TV sur KT était significativement associée à l’endocardite et au décès (p = 0,02). Dans cette première étude sur le sujet, un état inflammatoire cutané et biologique, un sepsis et une dénutrition sévère étaient associés à la survenue de TV sur KT chez les patients suivis pour une EBDR. Une recherche active de cette complication et un traitement anticoagulant adapté préventif semblent indiqués chez les patients présentant ces facteurs de risque.