Sreh Abuajela, Nakeshree Shailesh, Krishnasamy Senthil-Kumar, Alfasi Nuri
General Internal Medicine, Walsall Manor Hospital, United Kingdom.
Geriatrics and General Internal Medicine, Walsall Manor Hospital, United Kingdom.
Eur J Case Rep Intern Med. 2018 Jan 31;5(1):000713. doi: 10.12890/2017_000713. eCollection 2018.
This case demonstrates the therapeutic challenges encountered when managing an acute pulmonary embolism in a cancer patient with thrombocytopenia. A 64-year-old man with a history of lung cancer receiving chemotherapy was admitted to Walsall Manor Hospital with haemodynamic instability consistent with a pulmonary embolism, proven on computed tomographic pulmonary angiogram. His platelet count was noted to be 35×10/l (chemotherapy-induced thrombocytopenia). After discussions, he was deemed not suitable for thrombolysis based on risk versus benefits. The patient was initially transfused one adult dose of platelets and treated with half the therapeutic dose of low molecular weight heparin (LMWH). The same management plan was followed until the platelet count exceeded 50×10/l, after which the patient was established on the full therapeutic dose of LMWH. Clinically, the patient improved and was discharged. Three months after discharge, follow-up revealed sustained clinical improvement while the patient continued to be on the full therapeutic dose of LMWH with a stable platelet count.
Cancer patients have a three-fold higher risk of venous thromboembolism compared with non-cancer patients, but also a higher risk of bleeding, hence neoplasm is considered an absolute contraindication to thrombolysis by the European Society of Cardiologists.The management of an acute pulmonary embolism in cancer patients with thrombocytopenia is still debated. However, a few recognised medical societies and expert opinions have established recommendations on this specific area, such as the British Committee for Standards in Haematology, the American Society of Clinical Oncology and the International Society of Thrombosis and Haemostasis.Expert opinion agrees on: giving the full therapeutic dose of low molecular weight heparin (LMWH) if the platelet count is above 50×10/l; if it drops below 50×10/l, halving the dose of LMWH with or without platelet transfusion until the platelet count improves above 50×10/l; and when the platelet count is below 20-30×109/l, withholding anticoagulation and considering the insertion of an inferior vena cava filter.
本病例展示了在管理一名患有血小板减少症的癌症患者的急性肺栓塞时所遇到的治疗挑战。一名64岁有肺癌病史且正在接受化疗的男性因血流动力学不稳定被收入沃尔索尔庄园医院，计算机断层扫描肺动脉造影证实为肺栓塞。他的血小板计数为35×10⁹/L（化疗引起的血小板减少症）。经过讨论，基于风险与获益，认为他不适合进行溶栓治疗。该患者最初输注了一剂成人剂量的血小板，并接受了半量治疗剂量的低分子量肝素（LMWH）治疗。在血小板计数超过50×10⁹/L之前，一直遵循相同的管理方案，之后患者开始接受全量治疗剂量的LMWH治疗。临床上，患者病情改善并出院。出院三个月后，随访显示临床持续改善，患者继续接受全量治疗剂量的LMWH治疗，血小板计数稳定。
与非癌症患者相比，癌症患者发生静脉血栓栓塞的风险高三倍，但出血风险也更高，因此欧洲心脏病学会认为肿瘤是溶栓的绝对禁忌证。对于患有血小板减少症的癌症患者急性肺栓塞的管理仍存在争议。然而，一些知名医学学会和专家意见已经在这一特定领域制定了建议，如英国血液学标准委员会、美国临床肿瘤学会和国际血栓与止血学会。专家意见一致认为：如果血小板计数高于50×10⁹/L，给予全量治疗剂量的低分子量肝素（LMWH）；如果血小板计数降至50×10⁹/L以下，将LMWH剂量减半，可伴或不伴血小板输注，直至血小板计数升至50×10⁹/L以上；当血小板计数低于20 - 30×10⁹/L时，停用抗凝治疗并考虑植入下腔静脉滤器。
