AN UNUSUAL “BLACKBERRY SHAPED” MASS OF DUBIOUS INTERPRETATION (OUT OR IN THE JUGULAR VEIN?) IN A PATIENT WITH METASTATIC MELANOMA. A SPECIAL IMAGING CLINICAL CASE

Abstract A 43 y–o woman, without cardiovascular risk factors, was diagnosed with BRAF+ IIIC melanoma of unknown origin with bilateral axillary lymph node metastases. She started a combined treatment with vemurafenib, cobimetinib (braf/mek inhibitors) and atezolizumab (PDL1 inhibitor) as neoadjuvant therapy, followed after 6 weeks by surgical treatment (that showed pathological complete response) and adjuvant immunotherapy with atezolizumab hitherto ongoing. A serial CT–scan revealed a 0.9x1.3 cm mass (Fig.1) close to the right jugular vein (RJV) with increased contrast enhancement susceptible of vessel ectasia by the radiologist who expressed uncertainty about its site (intra or extravascular?) and asked for further imaging assessment. Therefore, a duplex ultrasound (DU) was performed with the detection of a 0.6x1.2 cm endovascular mobile “blackberry shaped” mass in the RJV and the indication for a vascular surgery evaluation. The patient started enoxaparin 1 mg/Kgx2/die s.c. according to “ex iuvantibus therapy”. However, the vascular surgeon diagnosis confirmed the undetermined site of the mass. The patient decided for a second DU opinion and reached our Cancer Angiology Lab, where a novel DU detected a deep vein thrombosis (DVT) of the RJV (Fig.2–Fig.3). Enoxaparin was replaced with edoxaban 60 mg 1 cp/die since the patient preferred a more manageable root of administration for the requested long–term anticoagulant treatment. After 2 months a DU follow up showed no regression of the mass. Accordingly, the patient proceeded with edoxaban 60 mg/die without any side effects, whereas still in treatment with immunotherapy. Conclusions Thromboembolism is the second leading cause of death in malignancy. Overall, biomarkers and thrombotic risk factors related to patient, tumor and anticancer regimens favor the development of cancer associated thrombosis. Delay in DVT diagnosis and, mostly, in the initiation of a full and long–term anticoagulant treatment, like in this case, enables a chronic evolution of the clot which makes its timely regression more challenging.