High prevalence and risk factors of thromboembolism in stage IV melanoma.

BACKGROUND: Patients with cancer are at a high risk of thromboembolism (TE), which contributes to morbidity and mortality. Several case reports of thromboembolic events have been reported in patients with melanoma in the literature. OBJECTIVE: The aim of this study was to evaluate the prevalence of venous thromboembolism (VTE) in stage IV melanoma and determine risk factors, outcomes associated with the development of VTE and the number of haemorrhagic complications in patients under anti-coagulant treatment. PATIENTS AND METHODS: In this retrospective study, we included all consecutive patients with stage IV melanoma among 290 patients followed-up in the department of Dermatology each year between January 2005 and 31 December 2007. The diagnosis of VTE was confirmed by venous ultrasound, pulmonary perfusion-ventilation technetium scan and angiography. The primary outcome was to evaluate the number of TE diagnosed in stage IV melanoma patients. The secondary outcomes were to study the influence of TE on survival, its prevalence according to metastatic sites and to evaluate the number of haemorrhagic complications. RESULTS: Twenty-four VTE events were found [25.2% (CI: 16.5-34)]. Eighteen VTE were deep venous thrombosis in lower limbs associated with pulmonary embolism (PE) in 50% of cases. Twenty-five percent were asymptomatic and were revealed in the pulmonary scan performed for follow-up. Eight percent of VTE events revealed stage IV melanoma. Seventeen patients developed thrombosis at home after stopping heparin prophylaxis. Seven thrombotic events occurred during oral anti-coagulant therapy. CONCLUSION: We found as high a prevalence of VTE in stage IV melanoma as in lung and gastrointestinal cancers. All patients suffered thrombotic events when they were treated with chemotherapy and at home when they stopped heparin prophylaxis. Therefore, heparin prophylaxis should be maintained at home.

[Herpetic recurrent upper limb lymphangitis]. / Lymphangite récurrente du membre supérieur d'origine herpétique.

Upper limb lymphangitis often complicates varied wounds on the hand or forearm and improvement is obtained in a few days with adapted antibiotic therapy. A 28-year-old woman presented since few years episodes of lymphangitis of the arm associated with vesicles on an erythematous base, on the palmar face of the first phalanx of the index finger, spontaneous relief within 10 days, without antibiotic therapy. Herpetic origin was confirmed on viral culture. No primary infection neither recurrence was noted. Because of the recurrences, a prophylactic treatment with valaciclovir was instituted. There was no reported recurrence at two years follow-up. Upper limb lymphangitis rarely complicates herpetic whitlow in immunocompetent patient. Clinicians should be aware of viral lymphangitis, which is often overlooked and associated with diagnostic errors and treatment delay.

[Primary cutaneous large B-cell lymphoma in chronic venous leg ulcer]. / Lymphome B primitif à grandes cellules CD20-, CD79a+ apparu sur un ulcère veineux chronique de jambe.

BACKGROUND: Large B-cell lymphoma of the leg in elderly subjects, of intermediate prognosis according to the new EORTC classification, may present as nodular or ulcerated forms. There has been relatively little study of the various etiological hypotheses advanced, including venous insufficiency. We report the case of an elderly man with chronic leg ulcer, recently undergoing modification, in which microscopy revealed large B-cell lymphoma (CD20-). PATIENTS AND METHODS: A 78 year-old man presented chronic ulcer of the right leg of mixed origin with severe venous insufficiency and arteritis. In the previous 2 months, 2 nodules appeared in the centre of the ulcer. Histological examination of a skin biopsy revealed the presence of large B-cell lymphoma and immunohistochemical analysis showed positive anti-CD79a+, CD20- antibody labeling of cells. Staging studies showed only locoregional invasion. Because of the positive CD20- labeling, ZEM chemotherapy (idarubicine, cyclophosphamide, prednisolone) was given, resulting in disappearance of the nodules after four months and preliminary epidermal healing of the ulcer. Several months later, severe infectious complications necessitated amputation. Examination of the excised sample showed no residual tumor. DISCUSSION: Many causal links have been proposed between large B-cell lymphoma of the leg and aetiologies such as infectious agents, Koebner phenomenon and chronic lymphedema, as well as various other vascular factors. A number of hypotheses were proposed in the present case. It may have been leg ulcer cutaneous B-cell lymphoma, or, more likely, development of lymphoma on a chronic mixed ulcer, with the respective roles of vascular disease, local immunosuppression and antigenic stimulation subject to debate.