Saddle Pulmonary Embolism in a Cancer Patient with Thrombocytopenia: A Treatment Dilemma
Table 1
Summary of guidelines for treatment of VTE in cancer [11–15].
Condition
ASCO
NCCN
AIOM/ESMO
ACCP
Initial treatment (acute phase)
- 5–10 days = LMWH preferred
- LMWH, UFH (IV), FXa-I according to clinical situation
- LMWH, UFH (IV) For CrCl less than 25–30 mL/min, either LMWH, UFH with antiXa monitoring
- LMWH or VKA for minimum of 90 days
Long-term treatment (chronic phase)
- LMWH for 180 days - If LMWH not available then VKA - indefinite in active disease
- LMWH preferred - Indefinite in patients with active and persistent RF - DVT for 3–6 months - PE for 6–12 months
- LMWH for 90–180 days - Long-term for patients with active cancer
- LMWH or VKA for as long as cancer active
Thrombolytic for initial treatment
Only in limb-threatening thrombosis
Massive DVT or PE with hemodynamic instability
NA
NA
IVCF
- Presence of CI - Recurrent VTE despite AC
- Presence of CI - New PE that might be life-threatening of PHTN
- Presence of CI - Recurrent PE despite treatment
- In patients with acute PE, if anticoagulant is not possible due to high-risk of bleeding - As soon as risk of bleeding is minimal, AC should be started
VTE: venous thromboembolism; ASCO: American Society of Clinical Oncology; NCCN: National Comprehensive Cancer Network; AIOM: Italian Association of Medical Oncology; ESMO: European Society of Medical Oncology; ACCP: American College of Chest Physician; LMWH: low-molecular-weight-heparin; UFH: unfractionated heparin; FXa-I: factor- Xa inhibitor; VKA: vitamin K antagonist; RF: risk factors; DVT: deep-vein thrombosis; PE: pulmonary embolism; IVCF: inferior vena-caval filter; CI: contraindication; PHTN: pulmonary hypertension; AC: anticoagulation; IV: intravenous; NA: not addressed. CrCl: creatinine clearance.