Booklet for Hemato-Oncologists
Case 15 (A, B) - Pain and swelling at the right shoulder during the induction phase including prednisone and L-ASP. Thrombus in the port-a-cath system.
A 15 months old male with intermediate risk pre-B ALL developed a non-specific pain and some swelling of the right shoulder on day 22 of the ALL-BFM 95 induction therapy, while receiving prednisone and L-Asparaginase, 4 doses of 5,000 U/m². The porth-a-cath system, which was placed in the right vena subclavia, when leukemia was diagnosed, appeared to be occluded by a thrombus. The occlusion did not allow the intraluminal administration of Urokinase.
A - Which diagnostic step do you plan?
1. A coagulation profile for fibrinogen, protein C, protein S, antithrombin, lupus anticoagulant test and identification of hereditary thrombophilic factors like MTHFR, F. V Leiden (APC resistance) and prothrombin G 20210 A variant
2. Duplex sonography
3. CT/MR angiography
4. All above mentioned
B - Which therapy for obstruction removal of the thrombus in the indwelling central venous catheter has to be given ?
1. Urokinase: 1,000 U/kg/h or rt-PA (recombinant tissue activator of plasminogen) 0.05 mg/kg/h without bolus for 3-hour cycles (up to 4-times) until lysis of the thrombus
2. Supplementation of low molecular weight heparin 100 U/kg/d
3. Removal of the porth-a-cath system
4. Thrombolytic therapy as mentioned in 1 and 2
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