CONGRESS ABSTRACT

A 68 y-o woman, treated with propranolol for hypertension, amiodarone due to a previous atrial flutter and levothyroxine for previous thyroidectomy, developed bilateral pleural effusion (dx > sn) and recurrent pericardial effusion (max 5 cm) treated with pericardiocentesis. After complaining for uterine non-major bleedings complicated by anemia (Hg: 9.9 g/dl), she was diagnosed with M1c BRAF wild-type IV stage vulva melanoma with bladder, endometrial and soft tissues metastases. Admitted to our hospital, she started nivolumab and ipilimumab replaced by carboplatin and paclitaxel and, lastly, nemvaleukin. An ECG showed a negative T wave in V2-V4 (Fig.1). Despite asymptomatic, her HS-Troponin was high (T1: 183 pg/mL, T2: 195 pg/ml). Echocardiogram (Eco) showed a slight pericardial effusion without tamponade, a normal EF (59%) and severe septal hypertrophy (18 mm), without right heart enlargement or dysfunction. Moreover, a 1.7 x 2.1 cm hyperechogenic mass attached to the roof of the right atrium without tricuspid valve orifice involvement, suggestive of blood clot, was detected (Fig.2). Therefore, she started enoxaparin 0.5 mg/kgx2/die. However, the CT-scan revealed further intracardiac lesions not Eco highlighted suggestive for multiple intracardiac and pericardial metastases (Fig.3), together with subsegmental and segmental filling defects of the right pulmonary artery. Accordingly, enoxaparin dose was increased to 1 mg/kgx2/die (Hg: 10 g/dl); however, at discharge, heparin could not be replaced by direct oral anticoagulants (DOACs) due both to the uncertainty of drug-drug interactions (DDI) with nemvaleukin and anemia. At the 3-month follow up, she was asymptomatic, still on nemvaleukin without substantial enlargement of the heart metastases. In accordance with the pulmonary embolism (PE) regression and the patient’s preference for a more practical anticoagulant therapy, we halved enoxaparin dose (1 injection/die instead of 2). Conclusions: Thromboembolism is the second leading cause of death in malignancy after cancer progression. Cardiac metastases are a rare condition, mostly due to pleural mesothelioma, lung-renal-breast cancer, lymphoma and melanoma. In this challenging clinical case, the cancer journey of the patient with melanoma and cardiac metastases was further complicated by the occurrence of an incidental PE, whose injectable anticoagulant treatment could not be optimized into a more manageable DOAC option due to the lack of DDI data.