Background: TEV is a common cancer complication with 20% incidence.

Aims: LMWH is the standard therapy for efficacy, safety and ease of use. However, some scenarios are deeply challenging for intercurrent prothrombotic anticancer drugs.

Methods: Left internal giugular vein thrombosis

A 35 y-o man reported dysphagia, EGDS: esophagus ulcers, thyroid echography: thoracic mass compressing proximal borders. Vascular ultrasound: thrombosis of left internal giugular, subclavian, axillary and brachial veins; he began enoxaparin 4000 IU x2/die. CT: solid anterior-superior mediastinum vascularized mass (16 x 13 cm) incorporating great thoracic vessels with 20 cm cranio-caudal longitudinal extension with trachea dislocation. PET-CT: massive superior-anterior mediastinum pathological ¹⁸F-FDG accumulation suggestive for malignancy. Lung perfusion scan: absence of left lung perfusion. Angio-CT:  showed compression of pulmonary artery trunk and of branches. He presented marked asthenia, sweating and presyncope. D-dimer: 6026 µg/L, NT-proBNP: 1417 pg/mL. Mediastinum biopsy exhibited seminoma (ki67+: 65%), he started BEP Protocol (etoposide, cisplatin, bleomycin), till now. 

Results: Partial recalization of left internal giugular vein thrombosis

TTE: periaortic cuff from mediastinum mass which ab-extrinseco compressed pulmonary artery trunk and branches with occlusion of left one, right chambers dilatation, sovra-epatic veins and inferior vena cava (21 mm) ectasia, decreased inspiratory collapse, pulmonary hypertension (SPAP: 52 mmHg), EF: 55%. After 2 months enoxaparin, vein ultrasound: persistent DVT and positive CUS (Figure 1). So, we replaced enoxaparin with edoxaban 60 mg/die. After 1 month edoxaban, vein ultrasound showed initial recanalization of left internal giugular vein (Figure 2); D-dimer: 1554 µg/L. After 2 months BEP Protocol, CT: decrease mediastinum mass (6 x 12 cm) dimensions.

Conclusions: Cancer associated thrombosis is complex complication, worsening mortality, morbidity and decision making. Cancer stage and drugs favour development of severe thrombosis, not solvable with LMWH, the cornerstone anticoagulant therapy in cancer-related thrombosis. DOACs appear as new and successful therapeutical option, especially in most challenging cases of highly thrombotic profile after “heparin failure”.

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ISTH Congress Abstracts - https://abstracts.isth.org/abstract/heparin-failure-in-seminoma-related-dramatic-hypercoagulable-melieu-and-extended-vein-thrombosis-is-it-bep-protocol-ongoing-responsible/