Professor Agnes Y. Y. Lee  加拿大Henderson 研究中心 副教授
 

Internet Circulation: Please talk about the effects of low molecular weight heparins on venous thromboembolism and survival in patients with cancer?

国际循环：请谈一下低分子量肝素治疗癌症静脉血栓栓塞患者的疗效和生存率？

 Internet Circulation: LMWHs are the first line drug of choice for Professor Lee: initial treatment and prevention of venous thrombembolism.  They are more efficacious and safer than unfractionated heparin (UFH)， more convenient and cost effective.  They are also more efficacious than warfarin for the long-term treatment of VTE in cancer patients.  Major disadvantages are the limited data in patients with renal insufficiency， hemodynamic instability and the low risk of heparin induced thrombocytopenia. Base on meta-analyses， LMWH is also associated with improved survival compared with UFH and warfarin.  But the data are not definitive and are needed in specific tumour types.

Professor Lee:  LMWH是预防和初始治疗静脉血栓栓塞的一线药物。他们比普通肝素（UFH）更有效、更安全、更方便，费用也低。他们对癌症VTE患者的长期治疗上比华法林更有效。主要的缺点是对于肾功能不全，血流动力学不稳定和肝素诱导的血小板减少症低风险患者的数据有限。根据荟萃分析显示， LMWH比肝素和华法林在提高生存率方面更有效，但是有待于进一步证实，特别是对肿瘤患者。

Internet Circulation: Would you please give us some advice on the prevention of deep vein thrombosis in cancer patients?

国际循环：癌症患者深静脉血栓的形成的预防上能给我们一些建议么？

Professor Lee: Routine primary prevention is recommended for all cancer patients admitted to the hospital for medical or surgical reasons. Routine primary prevention is recommended for patients with multiple myeloma receiving thalidomide- or lenalidomide based combination therapy with steroids or chemotherapy. Routine primary prevention is NOT recommended for patients with solid tumours receiving outpatient chemotherapy.  However， recent trials presented (in asbtract form) in patients with advanced pancreatic cancer shows a benefit in reducing thrombosis without increasing bleeding.  Whether this will change clinical practice or guideline recommendations is unknown at this point. See the ASCO guidelines.

 Professor Lee: 对于因内科或外科原因住院的所有的癌症患者推荐进行一级预防。对于多发性骨髓瘤沙利度胺或者来那度胺基础上联合固醇雷或者化疗药物进行一级预防。对于出院接受化疗的实体肿瘤患者不推荐使用一级预防。但是，最近的临床试验显示（摘要形式），对于晚期胰腺癌症患者可以从预防血栓而且没有出血并发症中获益。在这一点上是否可以改变临床实践或者指南还不确定。可以参考ASCO 指南。

Internet Circulation:  Please talk about your opinion on the efficacy of fondaparinux for the treatment of the venous thromboembolism in pulmonary cancer patients? And what about  the course of the therapy， or the indication of drug withdrawal？

国际循环：请谈一下您对磺达肝癸钠治疗肺癌患者静脉血栓栓塞的有效性的看法？治疗的疗程或者是撤药的指征？

 Professor Lee:  Data for fondaparinux in cancer patients is very limited.  There was a recent publication of the subgroup of cancer patients in the MATISSE trials for DVT and PE ( van Doormaal et al Thromb Haemost 2009)  The evidence did not show a difference between fondaparinux and UFH in PE patients， but fondarparinux was less effective than enoxaparin in reducing DVT recurrence，  but the numbers were small.

 Professor Lee: 磺达肝癸钠治疗癌症患者静脉血栓栓塞的数据非常有限。最近发表过的一篇关于MATISSE临床试验中癌症患者DVT和PE亚组分析显示，磺达肝癸钠与UFH治疗PE患者上的证据没有显著性。但是磺达肝癸钠在降低DVT发生率上比伊诺肝素更有效，但是数量较少。

Internet Circulation: After deep vein filter replacement on the pulmonary tumor patients complicated by DVT， please talk about your experience on anticoagulation of the patients to prevent from the recurrence of DVT or occlusion of the filter.

国际循环：请谈一下肺肿瘤合并DVT患者静脉滤器植入后预防DVT复发或者滤器堵塞的抗凝经验？

 Professor Lee:  In patients with cancer， I only place filters in when the patient is actively bleeding or needs urgent surgery AND has had a recent thrombotic event (within the past month).  Reason is that filters are often thrombosed in cancer patients and thrombosis can develop proximal to the filter and patients get PE anyways.  If a permanent filter is placed， then the patient with cancer needs to remain on anticoagulation to prevent recurrent DVT. 

 Professor Lee:  对于癌症患者，我只对两种患者放置腔静脉滤器，有活动性出血或者需要紧急外科手术的患者，和近期有血栓事件的患者（过去1个月）。原因是对于癌症患者，滤器经常引起血栓形成，而且会在滤器近端形成血栓而使患者发生PE。如果是永久性滤器置入，那么癌症患者需要保持抗凝以预防DVT的发生。

Internet Circulation:  Please talk about the accuracy and usefulness of D-dimer testing in excluding deep vein thrombosis in cancer patients.

国际循环：D-dimer在排除癌症患者深静脉血栓上的准确性和实用性？

Professor Lee:  D-dimer testing should not be used in cancer patients to exclude a diagnosis of DVT or PE.  The data are very， very limited and the false negative values are up to 20% in some series， depending on the type of D-dimer assay used.  Because most cancer patients have a moderate to high risk of thrombosis， D-dimer testing should not be done.  See the recent paper from Carrier et al in Thromb Res 2008.

 Professor Lee: D-dimer 检测不会用于癌症患者来排除DVT或者PE的诊断，数据非常非常的有限，某些测定中假阳性率可达20%，取决于D-dimer测定的种类。因为大部分癌症患者存在中度到高度的栓塞风险，D-dimer检测不应该进行。可以参看Carrier et al在2008年发表在Thromb Res上的文章