Mesothelioma and venous thrombosis
==================================

* Henry Schneiderman

Ami Schattner and Natasha Kozack describe and illustrate a unique and unfamiliar physical sign.1 Better-known differential diagnoses for enlarged supraclavicular fossae include obesity and Cushing's syndrome. The one time that I observed such enlargement unilaterally was in an obese woman who had lost much supraclavicular soft-tissue volume through remote full radical mastectomy.2 This patient's cortisol levels were normal. 

With regard to Virchow's triad, the injury that predisposes to thrombosis damages the endothelium, not the epithelium, and the specific abnormality of blood flow is stasis. In the case described by Schattner and Kozack,1 lack of flow was likely fostered not merely by proximity of the tumour but also by extrinsic compression of the internal jugular vein or any of the more proximal veins, such as the left innominate vein. The resultant venous stasis and venous hypertension would be transmitted to the internal jugular vein, which would in turn predispose to thrombosis of the latter. Alternatively, primary thrombosis that occurred proximally might have been propagated distally. 

It would be of interest if Schattner and Kozack could report the state of the great veins at the time of surgery, on the basis of either imaging or direct observation during the operation, as well as the local findings if an autopsy was performed when the patient died, 3 months later. 

**Henry Schneiderman** Hebrew Health Care University of Connecticut School of Medicine West Hartford, Conn.

## References

1.  1. Schattner A, Kozack N. A 47-year-old man with mesothelioma and neck swelling. CMAJ 2004; 170 (4):465. 
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNzAvNC80NjUiO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTcxLzEvMTEuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  2. Schneiderman H. Severely disfiguring therapy for breast cancer, and the evolution of medicine. Consultant 1997;37:1006-14.