Clinical Observations and Molecular Variables of Primary Vascular Leiomyosarcoma

Primary IVC Leiomyosarcoma: A Case Series and Review of the Literature

Leiomyosarcomas of the inferior vena cava (IVC) are the most common primary malignancy of the IVC; however, these lesions are extremely rare. These lesions are slow-growing, often asymptomatic and, present late in the disease course portending a poor prognosis. Surgical resection is considered the standard of care and only potential curative treatment. Progression free survival rates after surgical resection have been estimated to be 31.4% after five years and 7.4% after 10 years. To date, there have been a total of 418 cases documented within small and large single center institutional case series. Here, we present a case series from a single institution and a comprehensive literature review to investigate the presentation, treatment, and outcomes of this rare lesion. A surgically relevant designation of tumor location to include involvement of the renal veins is proposed.

Extent of macroscopic vascular invasion predicts distant metastasis in primary leiomyosarcoma of the inferior vena cava

BACKGROUND

In retroperitoneal leiomyosarcoma (RP LMS), the predominant issue is distant metastasis (DM). We sought to determine variables associated with this outcome and disease-specific death (DSD).

METHODS

Data were retrospectively collected on patients with primary RP LMS treated at a high-volume center from 2002 to 2023. For inferior vena cava (IVC)-origin tumors, the extent of macroscopic vascular invasion was re-assessed on each resection specimen and correlated with preoperative cross-sectional imaging. Crude cumulative incidences were estimated for DM and DSD and univariable and multivariable models were performed.

RESULTS

Among 157 study patients, median tumor size was 11.0 cm and 96.2% of cases were intermediate or high grade. All patients underwent complete resection, 56.7% received chemotherapy (43.9% neoadjuvant) and 14.6% received radiation therapy. Only tumor size and grade and not site of tumor origin (e.g., IVC vs. other) were associated with DM and DSD (p < 0.05). Among 64 patients with IVC-origin tumors, a novel 3-tier classification was devised based on the level of intimal disruption, which was associated with both DM (p = 0.007) and DSD (0.002).

CONCLUSION

In primary RP LMS, only tumor size and grade are predictive of DM and DSD. In IVC-origin tumors, the extent of macroscopic vascular invasion is also strongly predictive of these outcomes.

Surgical and oncologic approach to leiomyosarcoma of the inferior vena cava: A case report

Key Clinical Message

LMS of IVC needs a multidisciplinary approach. Surgical excision with free margin is the cornerstone of management. Upon case-by-case selection, adjuvant chemotherapy may play a role in better oncologic outcome.

Abstract

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare form of mesenchymal origin malignancy with less than 400 cases reported to date. Surgery is the mainstay of management but it requires vast experience in vascular and visceral surgery to attain a free tumor margin. Subsequent adjuvant treatment with chemotherapy and radiation remains as an area of gray zone. We report the case of a 61-year-old man with an 8-month history of abdominal pain. Upon physical examination, an ill-defined mass over the right side of the lower abdomen and bilateral lower extremity edema were detected. Abdominal ultrasound with Doppler revealed a right-side retroperitoneal mass invading the IVC with extensive venous thrombosis for which anticoagulation was initiated. Computed Tomography of the abdomen revealed a huge heterogeneously enhancing mass involving the whole length of the infrarenal IVC obstructing the IVC lumen with collateral veins draining through the paralumbar veins and inferior epigastric veins bilaterally. With a top differential of primary IVC LMS, a midline longitudinal laparotomy was performed with an intraoperative finding of a tumor arising from the infra-renal IVC which was excised. Gore-Tex graft was used to reconstruct the IVC. There was an injury to the right common iliac artery and it was repaired by end-to-end anastomosis. Histopathology confirmed a high-grade LMS of the IVC and surgical margin status was unknown. He was given adjuvant Chemotherapy consisting of Doxorubicin and Dacarbazine. He has been on follow-up at the Oncology side with a good performance status.

Molecular Heterogeneity in Leiomyosarcoma and Implications for Personalised Medicine

OPINION STATEMENT

Leiomyosarcoma (LMS) is one of the more common subtypes of soft tissue sarcomas (STS), accounting for about 20% of cases. Differences in anatomical location, risk of recurrence and histomorphological variants contribute to the substantial clinical heterogeneity in survival outcomes and therapy responses observed in patients. There is therefore a need to move away from the current one-size-fits-all treatment approach towards a personalised strategy tailored for individual patients. Over the past decade, tissue profiling studies have revealed key genomic features and an additional layer of molecular heterogeneity among patients, with potential utility for optimal risk stratification and biomarker-matched therapies. Furthermore, recent studies investigating intratumour heterogeneity and tumour evolution patterns in LMS suggest some key features that may need to be taken into consideration when designing treatment strategies and clinical trials. Moving forward, national and international collaborative efforts to aggregate expertise, data, resources and tools are needed to achieve a step change in improving patient survival outcomes in this disease of unmet need.

Unresectable leiomyosarcoma of the inferior vena cava with right atrium tumor thrombus: when to deem this tumor inoperable? A case report and literature review

Leiomyosarcomas (LMS) of the inferior vena cava (IVC) are a rare form of retroperitoneal malignancy, and their venous extension to the right atrium is an even rarer event. These tumors pose a unique surgical challenge and often require a multidisciplinary team-based approach for their surgical treatment. We present a case of a 68-year-old man with primary LMS of the IVC with a tumor thrombus extending into the right atrium that was initially deemed inoperable. After extensive neoadjuvant chemo-radiation with minimal tumor effect, the patient underwent en bloc surgical resection of the tumor along with removal of the infrarenal IVC and right kidney and adrenal without the need for cardiopulmonary bypass. This case demonstrates the successful management of a primary LMS of the IVC with right atrial extension using a multimodal approach of neoadjuvant chemo-radiation and en bloc surgical resection without cardiopulmonary bypass. This strategy may offer a curative option for selected patients with these rare and aggressive tumors, improving their survival and quality of life.

Aggressive surgical approach with vascular resection and reconstruction for retroperitoneal sarcomas: a systematic review

BACKGROUND AND AIM

Surgery is the mainstay of treatment and completeness of surgical resection is critical to achieve local control for retroperitoneal sarcoma (RPS). En-bloc resection of adjacent organs, including major abdominal vessels, is often required to achieve negative margins. The aim of this review was to summarise the available evidence to assess the relative benefits and disadvantages of an aggressive surgical approach with vascular resection in patients with retroperitoneal sarcoma (RPS).

METHODS

We searched PubMed, the Cochrane Library, and EMBASE for relevant studies published from inception up to August 1, 2022. We performed a systematic review of the available studies to assess the safety and long-term survival results of vascular resection for RPS.

RESULTS

We identified a total of 23 studies for our review. Overall postoperative in-hospital or 30-day mortality rate of patients with primary iliocaval leiomyosarcoma was 3% (11/359), and the major complication rate was 13%. The recurrence-free survival (RFS) rates after the follow-up period varied between 15% and 52%, and the 5-year overall survival (OS) rates ranged from 25 to 78%. Overall postoperative in-hospital or 30-day mortality rate of patients with RPSs receiving vascular resection was 3%, and the major complication rate was 27%. The RFS rates after the follow-up period were 18-86%, and the 5-year OS rates varied between 50% and 73%. There were no significant differences in the rates of RFS (HR: 0.97; 95% CI: 0.74-1.19; p = 0.945) and OS (HR: 1.01; 95% CI: 0.66-1.36; p = 0.774) between the extended resection group and tumour resection alone group.

CONCLUSIONS

With adequate preparation and proper management, for patients with RPSs involving major vessels, aggressive surgical approach with vascular resection can achieve R0/R1 resection and improve survival.

Deciding individual treatment for primary retroperitoneal sarcoma

INTRODUCTION

Retroperitoneal sarcomas (RPS) are rare mesenchymal tumors that account for only 0.1-0.2% of all malignancies. Management of this disease is challenging, and resection remains the cornerstone of treatment. Ongoing international collaboration has expanded our knowledge of this disease, allowing for a more personalized approach to RPS patients resulting in improved survival over time. Due to the heterogeneity of RPS, with differing recurrence patterns and sensitivities to neoadjuvant therapies based on histology and grade, management of RPS should be tailored to the individual patient.

AREAS COVERED

Our review focuses on a histology-driven approach in the management of primary RPS. We searched relevant articles from 1993 to 2023 that investigated prognostic factors and treatment of patients with RPS and summarized recent advances and future directions in the field.

EXPERT OPINION

Deeper understanding of the role of neoadjuvant radiotherapy and ongoing trials investigating the role of neoadjuvant chemotherapy will potentially contribute to the development of individualized treatment pathways.

Primary leiomyosarcoma of the inferior vena cava in a pediatric case: a case report and literature review

BACKGROUND

Leiomyosarcoma is classified as a soft tissue sarcoma. In adults, leiomyosarcoma is the most common malignancy affecting the vascular system; however, vascular leiomyosarcoma in children is extremely rare as most pediatric soft tissue tumors are rhabdomyosarcomas. The survival rate is very low, and incomplete resection is a poor prognostic factor. There is also a high rate of distant recurrence, with the lungs and liver being the most common sites of metastasis. There is no established effective chemotherapy, and complete surgical resection is the only potentially curative treatment for leiomyosarcoma.

CASE PRESENTATION

A 15-year-old female patient with no significant medical history presented with severe upper abdominal pain and was admitted. Abdominal contrast-enhanced computed tomography and magnetic resonance imaging showed a large retroperitoneal tumor protruding into the lumen of the inferior vena cava behind the liver and multiple small nodules, and metastasis to the liver was suspected. The tumor was 6 × 4 × 5 cm in diameter, located just behind the hepatic hilar structures, and was suspected to infiltrate into the right portal vein. The tumor was diagnosed as a leiomyosarcoma through an open tumor biopsy. As the multiple liver metastases were located only in the right lobe of the liver on imaging, we performed tumor resection with right hepatectomy and replacement of the inferior vena cava (IVC). The postoperative course was uneventful; however, on postoperative day 51, distant metastatic recurrences were found in the remaining liver and right lung. The patient was immediately started on chemotherapy and trabectedin proved to be the most effective drug in the treatment regimen; however, severe side effects, such as hepatotoxicity, prevented timely administration, and the patient passed away 19 months after surgery.

CONCLUSIONS

IVC resection and reconstruction combined with right hepatectomy were able to be safely performed even in a pediatric case. To improve the prognosis of leiomyosarcoma with multiple metastases, an effective treatment strategy combining surgical treatment and chemotherapy, including molecularly targeted drugs, should be established as early as possible.

Targeting the Molecular and Immunologic Features of Leiomyosarcoma

Leiomyosarcoma (LMS) is a rare, aggressive mesenchymal tumor with smooth muscle differentiation. LMS is one of the most common histologic subtypes of soft tissue sarcoma; it most frequently occurs in the extremities, retroperitoneum, or uterus. LMS often demonstrates aggressive tumor biology, with a higher risk of developing distant metastatic disease than most sarcoma histologic types. The prognosis is poor, particularly in patients with uterine disease, and there is a need for the development of more effective therapies. Genetically, LMS is karyotypically complex and characterized by a low tumor mutational burden, with frequent alterations in TP53, RB1, PTEN, and DNA damage response pathways that may contribute to resistance against immune-checkpoint blockade monotherapy. The LMS immune microenvironment is highly infiltrated with tumor-associated macrophages and tumor-infiltrating lymphocytes, which may represent promising biomarkers. This review provides an overview of the clinical and pathologic behavior of both soft tissue and uterine LMS and summarizes the genomic and immune characteristics of these tumors and how they may provide opportunities for the development of biomarker-based immune therapies.

Abnormal growth of a pleomorphic leiomyosarcoma originating from the mesenteric vein associated with poor outcome after curative-intent resection: a case report

Background

A leiomyosarcoma (LMS) is a rare tumor that mainly originates from the urinary tract and digestive system; however, non-visceral organ-derived patterns are rare. Herein, we report that a vessel-derived pleomorphic LMS (PLMS) originating from the mesenteric vein has a poor prognosis even after curative-intent surgery.

Case presentation

The patient was a 41-year-old woman with no relevant medical history. The patient presented with abdominal pain and an abnormal bulge on the left lower abdomen. Magnetic resonance imaging revealed a large tumor occupying the left abdomen. Enhanced computed tomography revealed a bulky tumor with a maximum size of 13 × 13 cm with impending rupture, and a small amount of ascites was detected around the tumor. As the tumor directly invaded the small intestine and descending colon, left hemicolectomy and partial resection of the small intestine were performed. The patient was discharged on postoperative day 10, without any complications. On histopathological analysis, the tumor was diagnosed as a vessel-derived LMS with a pleomorphic pattern. The patient died due to disseminated intravascular coagulation because generalized peritonitis was induced by the super-early recurrence of the tumor 2 months after the surgery.

Conclusions

Regardless of curative-intent surgery for a vessel-derived PLMS, super-early local recurrence and distant metastasis were observed. A vessel-derived PLMS requires further investigation to determine its characteristics and therapeutic strategies to improve long-term prognosis.

Case report: Surgical resection of a retro-hepatic leiomyosarcoma involving atrial reconstruction, cardiopulmonary bypass, ex vivo tumor resection, and liver re-implantation

INTRODUCTION

Leiomyosarcomas (LMS) involving the inferior vena cava (IVC) is a clinically rare entity, accounting for approximately 0.5% of all adult sarcomas.

CASE PRESENTATION

A 67-year-old male presented to the emergency department with mild back and lower abdominal pain. During the workup, a computed tomography scan without contrast showed an area of decreased attenuation within the liver adjacent to the intrahepatic IVC. Magnetic resonance imaging confirmed the involvement of the retro-hepatic IVC; biopsy confirmed the diagnosis of LMS. Given the location of the involvement of the retro-hepatic IVC, liver explantation was deemed necessary for adequate tumor resection. The superior extension of the tumor toward the heart necessitated Cardio-Pulmonary (CPB). The patient successfully underwent a complex surgical procedure involving liver explantation with ex vivo back-table resection of the retro-hepatic LMS, replacement of the retro-hepatic vena cava with a ringed Gore-Tex graft, liver re-implantation, and hepatic vein-atrial reconstruction under cardiopulmonary bypass. There were no intraoperative or post-op complications.

DISCUSSION

The role of vascular reconstruction of the IVC varies depending on the level and extent of the tumor, with options ranging from primary repair, ligation, or reconstruction dictated. Surgical resection with negative margins remains the treatment of choice due to the lack of efficacy of adjuvant therapies. Importantly, liver explantation offers a chance for complete surgical resection and reconstruction. Similarly, the complex nature of the tumor necessitated a pioneering approach involving direct hepato-atrial venous anastomosis.

CONCLUSION

To the best of our knowledge, this is the first reported case in which the hepatic veins were anastomosed directly to the right atrium while also replacing the native vena cava with a separate graft.

Resection of retroperitoneal tumors with inferior vena cava involvement without caval reconstruction

BACKGROUND AND OBJECTIVES

Retroperitoneal tumors with involvement of the inferior vena cava (IVC) often require resection of the IVC to achieve complete tumor removal. This study evaluates the safety and efficacy of IVC ligation without caval reconstruction.

METHODS

A retrospective chart review of patients who underwent IVC ligation (IVC-Ligation) and IVC resection with reconstruction (IVC-Reconstruction) at our institution between May 2004 and April 2021 was performed. Outcomes from the two surgical techniques were compared via univariate analysis using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables.

RESULTS

Forty-nine IVC-Ligation and six IVC-Reconstruction surgeries were identified. There were no differences in baseline demographics, tumor characteristics, complication rates, postoperative morbidity, or overall 5-year survival between groups. IVC-Reconstruction patients were more likely to require intensive care unit admission (83% vs. 33%; p = 0.0257) and the IVC-Ligation cohort had a tendency to present with nondebilitating postoperative lymphedema (35% vs. 0%; p = 0.1615), which resolved for most patients.

CONCLUSIONS

IVC-Ligation is a viable surgical option for select patients presenting with retroperitoneal tumors with IVC involvement and provides acceptable short- and medium-term outcomes.

Current update on IVC leiomyosarcoma

Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare soft tissue sarcoma associated with poor prognosis. Patients are often asymptomatic or present with nonspecific abdominal symptoms, which delays initial diagnosis and contributes to poor oncologic outcome. Key imaging modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Characteristic imaging features include imperceptible caval lumen, dilation of the IVC, heterogeneous enhancement of the tumor, and development of extensive collateral circulation. Surgical resection is the mainstay of treatment, while chemotherapy and/or radiation may serve as therapy adjuncts. This article reviews the pathology, clinical findings, imaging features and management of IVC leiomyosarcoma.

Surgical resection of leiomyosarcoma of the inferior vena cava: A case series and literature review

OBJECTIVES

We review our institution's experience in treating leiomyosarcomas involving the inferior vena cava, and we offer guidance on the management.

METHODS

A text-based search was performed to identify all patients who underwent surgical resection between January 2002 and October 2020. Clinicopathologic data, intraoperative variables, and outcomes were extracted from chart review.

RESULTS

Twelve of 16 patients (75%) had localized disease; the remaining had limited metastatic disease. Seven of 16 patients (44%) received neoadjuvant chemotherapy or radiation; three patients had partial responses, and four patients had stable disease using RECIST 1.1 criteria. IVC reconstruction was performed in 14 of 16 patients (88%); IVC was ligated for the remaining two patients. Half of all patients had R0 resection on final pathology; the remaining had R1 resections. Progression-free survival (PFS) and overall survival (OS) were not statistically different between patients with R0 and R1 resection. Median PFS was 1.8 years (95% CI 0.89 - not reached); median OS was 6.5 years (1.8 - not reached). Only one patient (6%) experienced local disease recurrence; 4 of 16 patients (25%) experienced disease recurrence distally without local recurrence.

CONCLUSIONS

Resection of IVC leiomyosarcomas at a sarcoma referral center with experience in vascular reconstruction can lead to many years of recurrence-free survival. Surgical resection should be offered to patients with a low volume of metastatic disease to reduce local complications from the primary tumor, many of which exert significant mass effect on surrounding organs. For patients with metastatic disease or large, high-risk tumors, neoadjuvant chemotherapy can provide a biologic test of disease stability prior to resection.

Surgical and reconstructive outcomes in primary venous leiomyosarcoma

OBJECTIVES

Primary venous leimyosarcomas (PVL) are rare and pose challenges in surgical management. This study evaluates the clinical outcomes and identifies predictors of survival in our surgical series of PVL.

METHODS

A retrospective review was performed of patients who had resection of PVL at three centers between 1990-2018. Patient demographics, comorbidities, intraoperative data, survival, and graft related outcomes were recorded. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression.

RESULTS

Seventy patients with a diagnosis of PVL were identified between 1990 and 2018. Fifty-four patients (77%) had PVL of the IVC and 16 (23%) had peripheral PVL. Mean follow up for the series was 55.0 months (range 1-217 months). Fifty one patients (96%) with IVC PVL needed caval reconstruction and 3 (4%) had resection only. There were no deaths within thirty days of surgery. Five patients (9%) required early re-intervention including one (2%) IVC stent. Sixteen peripheral PVL were identified. Eight patients (50%) had venous reconstructions performed and 8 (50%) had the vein resected without reconstruction. There were no deaths within thirty days. Five year survival was 57.5% for IVC PVL and 70.0% for peripheral PVL . Kaplan-Meier survival analysis for IVC and peripheral PVL revealed no difference in overall survival (p = 0.624) at 5 years.

CONCLUSIONS

PVL is a rare and aggressive disease even with surgical resection. We found no difference in survival between IVC and peripheral lesions suggesting aggressive management is warranted for PVL of any origin. Management of PVL requires a multidisciplinary approach to provide patients with the best long term outcomes.

Surgical resection and graft replacement for primary inferior vena cava leiomyosarcoma: a multicenter experience

OBJECTIVE

Primary leiomyosarcoma of the inferior vena cava (IVC) is best managed with surgical resection when technically feasible. However, consensus is lacking regarding the best choice of conduit and reconstruction technique. The aim of the present multicenter study was to perform a comprehensive assessment through the VLFDC (Vascular Low Frequency Disease Consortium) to determine the most effective method for caval reconstruction after resection of primary leiomyosarcoma of the IVC.

METHODS

A multicenter, standardized database review of patients who had undergone surgical resection and reconstruction of the IVC for primary leiomyosarcoma from 2007 to 2017 was performed. The demographics, periprocedural details, and postoperative outcomes were analyzed.

RESULTS

A total of 92 patients (60 women and 32 men), with a mean age of 60.1 years (range, 30-88 years) were treated. Metastatic disease was present in 22%. The tumor location was below the renal veins in 49 (53%), between the renal and hepatic veins in 52 (57%), and above the hepatic veins in 13 patients (14%). The conduits used for reconstruction included ringed polytetrafluoroethylene (PTFE; n = 80), nonringed PTFE (n = 1), Dacron (n = 1), autogenous vein (n = 1), bovine pericardium (n = 4), and cryopreserved tissue (n = 5). Complete R0 resection was accomplished in 73 patients (79%). In-hospital mortality was 2%, with a median length of stay of 8 days. The primary patency of PTFE reconstructed IVCs was 97% and 92% at 1 and 5 years, respectively, compared with 73% at 1 and 5 years for the non-PTFE reconstructed IVCs. The overall 1-, 3-, and 5-year survival for the entire cohort were 94%, 86%, and 65%, respectively CONCLUSIONS: The findings from our multi-institutional study have demonstrated that complete en bloc resection of IVC leiomyosarcoma with vascular surgical reconstruction in selected patients results in low perioperative mortality and is associated with excellent long-term patency. A ringed PTFE graft was the most commonly used conduit for caval reconstruction, yielding excellent long-term primary patency.

Metastatic Vascular Pleomorphic Leiomyosarcoma in a Previously Treated Cervical Carcinoma Patient: A Diagnostic Dilemma

Vascular leiomyosarcoma is a rare malignant tumour of the smooth muscle connective tissue. Patients are usually asymptomatic in the early stages and only present when the lesion causes compressive or obstructive effects or has metastasized. We report a case of vascular pleomorphic leiomyosarcoma in a 70-year-old lady with a background history of squamous cell carcinoma of the cervix. She presented with a three-month history of low back pain, which radiated to the anterior bilateral thigh. Initial radiological findings revealed metastatic lesions involving the spine and lungs. Two spinal biopsies done were inconclusive. Increasing severity of pain over the right thigh prompted further imaging, which revealed bilateral femoral lesions. The patient underwent surgery which involved excision of the tumour in the right proximal femur with skeletal reconstruction using megaprosthesis. Proximal femoral nail was performed for the left femur. Intra-operatively, tumour was noted at the anteromedial aspect of the proximal right thigh surrounding the superficial femoral vein. Histopathological report of the right thigh mass finally confirmed a diagnosis of vascular pleomorphic leiomyosarcoma. The patient presented four months later with bilateral pulmonary embolism with deep vein thrombosis in addition to progression of the disease.

Inferior vena cava reconstruction with a superficial femoral vein graft after resection of a venous leiomyosarcoma

Leiomyosarcoma is a rare malign neoplasm, representing about 5-7% of all tissue sarcomas while inferior vena cava leiomyosarcomas accounts for only 1%. This paper presents the case of a 74 years old patient that was diagnosed with an abdominal venous leiomyosarcoma involving the inter-renal segment of the inferior vena cava. Tumor was treated by complete in bloc resection. Reconstruction of the vascular axis was performed with an autologous venous tube graft achieved with segments of the right superficial femoral vein. Recurrent free survival and freedom from local or systemic recurrence was observed at 2 years after the intervention thanks to the aggressive radical surgical management.

Modern multimodality management of patients with caval leiomyosarcoma: New treatment paradigms and potential molecular insights

BACKGROUND AND OBJECTIVES

Caval leiomyosarcomas (cLMS) are rare soft tissue sarcomas historically associated with high recurrence rates and poor prognosis. While radical resection remains the mainstay of therapy for cLMS, new systemic therapies have presented opportunities for multimodality treatment. We examined the clinical outcomes of patients with cLMS treated with modern, multimodality approaches, and compared their outcomes to those of patients with noncaval retroperitoneal LMS (ncLMS).

METHODS

A retrospective, single-institution review identified all patients diagnosed with primary retroperitoneal LMS from 2012 to 2018. Radiographic and pathologic review distinguished patients with cLMS and ncLMS. Standard clinicopathologic variables and response to chemotherapy (when applicable) were analyzed. Primary endpoints were overall (OS) and progression-free survival (PFS).

RESULTS

Eleven patients with cLMS were identified. Median tumor size was 7.5 cm (IQR, 5.0-14.3 cm); all patients had Stage II/III disease. Seven patients received neoadjuvant chemotherapy. Nine cLMS patients underwent R0/R1 resection; two did not complete resection. Six patients received adjuvant systemic therapy. Twenty patients with ncLMS were treated during the same period. No statistical intergroup differences were noted in tumor size, pathologic grade, stage, or resection margin status. Patients with ncLMS were less likely to receive neoadjuvant (10% vs. 64%) and adjuvant chemotherapy (30% vs. 55%). Two-year OS (81% vs. 78%; p = NS) and PFS (55% vs. 46%; p = NS) were comparable between cLMS and ncLMS patients.

CONCLUSIONS

Multimodality treatment with systemic therapy and aggressive surgical resection may achieve equivalent survival outcomes for patients with cLMS versus similar ncLMS. We recommend that all patients with cLMS be evaluated for multidisciplinary treatment. Genomic and proteomic expression profiling may identify novel or targetable mutations.

Inferior Vena Cava Leiomyosarcoma: What Method of Reconstruction for Which Type of Resection?

Inferior vena cava leiomyosarcoma (IVCL) is a rare tumor with a poor prognosis, and its surgical resection remains a challenge. To date, surgery is the only potentially curative treatment for IVCL with a 5-year survival rate of 55%. The main challenge is to combine oncological surgery with clear margins and vascular reconstruction of the inferior vena cava (IVC). In this review, we discuss the different approaches to vascular reconstruction after IVCL resection, using a prosthetic or autologous patch, direct suture or simple ligation without IVC reconstruction. The reconstruction of IVC depends of tumor location and its extension. We recommend no reconstruction if venous collaterality is well-established. When vascular reconstruction is required, we prefer prosthetic PTFE graft. These patients should be referred to high-volume centers with a multidisciplinary team of sarcoma surgeons with cardiothoracic, vascular and hepatic specialties.

Chemoradiotherapy for Inoperable Carotid Body Leiomyosarcoma: A Case Report and Review of Literature

Vascular leiomyosarcoma is an extremely rare tumor and is associated with poor prognosis among leiomyosarcoma. Surgical resection remains the main treatment option. But outcome of definitive treatment with chemoradiotherapy in inoperable patients is not clear. Here, we report treatment and outcome of definitive chemoradiotherapy in a case of vascular leiomyosarcoma. A 64-year-old man with the initial presentation of pulsatile right neck mass was diagnosed with right carotid body leiomyosarcoma. He refused surgical intervention due to risk of carotid body injury and ischemic stroke. Successful tumor control was achieved with carboplatin-based concurrent chemoradiotherapy. Investigational liquid biopsy for circulating sarcoma cells was also performed to analyze drug sensitivity profile of this rare tumor. One year after treatment, the disease remained well controlled and there was no evidence of baroreflex failure or treatment-related late toxicities. To our best knowledge, this is the first case report of right carotid body leiomyosarcoma controlled with definitive concurrent chemoradiotherapy. The approach of personalized multi-modality treatment will be a focus of our future investigation.

Femoral Vein Leiomyosarcoma Mimicking Thrombosis

BACKGROUND

Leiomyosarcoma represents a diagnostic challenge since it is often misdiagnosed as deep venous thrombosis (DVT).

METHODS

A 49-year-old woman with history of DVT and diagnosed with recurrency of thrombosis came to our observation for right thigh pain persistency.

RESULTS

Duplex-Ultrasound (US) examination showed an oval mass inside the superficial femoral vein with color spots and blood flow signal in its context. Contrast enhanced computed tomography and magnetic resonance of the lower limbs showed the presence of vascularized lesion into the distal superficial femoral vein. Echo-guided biopsy revealed the presence of high grade leiomyosarcoma. A total body 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography demonstrated a rounded area of pathological increased FDG uptake, at the distal thigh level without metastatic localization.

CONCLUSIONS

Our experience demonstrated that a multimodality approach may help to distinguish leiomyosarcoma from a blood clot in doubtful cases.

Intravenous Leiomyosarcoma of the Lower Extremity: As Peripheral as It Gets

Leiomyosarcomas of the vascular system (vLMSs) are rare tumors that commonly originate from large proximal and central veins. Pancreatic metastasis is rare for sarcomas, and surgical excision with large margins is the treatment of choice. We present a case of a 32-year-old female with primary vLMS originating from the distal crural veins and local invasion of the fibula. A prior open biopsy site was suboptimal. The patient was treated with neoadjuvant chemotherapy and radiotherapy, followed by surgery. The follow-up radiological imaging showed pancreatic head metastasis, which is also an extremely rare site for vLMS.

Primary external iliac vein leiomyosarcoma in a young female diagnosed by contrast-enhanced ultrasound: A case report

RATIONALE

Venous leiomyosarcoma (LMS) is a malignant tumor arising from the smooth muscle cell of the vein wall. The diagnosis of venous LMS is usually delayed owing to its rarity, absence of serological markers, and mimicry with deep vein thrombosis (DVT). Herein, we report a case of a primary external ilian vein LMS characterized by long-term, unexplained DVT in the left lower limb. Contrast-enhanced ultrasound (CEUS) played a crucial role in the preoperative diagnosis. No improvement was observed in the lower limb status; a rapid, high-level, heterogeneous wash-in and wash-out mass of the vein, as seen with CEUS, could indicate angiogenic malignancy. CEUS also helped evaluate the percent of intratumoral necrosis, which is an important parameter for predicting the prognosis.

PATIENT CONCERNS

A 37-year-old Chinese women presented to the Vascular Surgery Department of our hospital for accurate diagnosis of her condition. She began experiencing edema and pain in her left leg 2 years ago. She was diagnosed with DVT in the left lower extremity and was administered anticoagulant therapy since then. However, her symptoms started to aggravate 8 months ago.

DIAGNOSES

The laboratory results including D-dimer, prothrombin time (PT), activated partial thrombin time (APTT), and prothrombotic conditions screening were within normal ranges. A pelvic ultrasound detected a heterogeneous, hypoechoic mass compressing the external iliac vein and obstructing the venous drain of the lower extremity. The mass showed a rapid, high-level, heterogeneous wash-in and wash-out on CEUS, which suggested angiogenic malignancy. Contrast-enhanced CT (CECT) confirmed the result of CEUS but revealed no metastasis.

INTERVENTIONS

She underwent complete surgical removal of the tumor, which was resected successfully. There was no infiltration in the inguinal nodes sent for the study.

OUTCOMES

Pathological examination and immunohistochemistry confirmed that the mass was a well-differentiated LMS originating from the external iliac vein. There was no sign of local recurrence or distant metastasis during a 12-month follow-up.

LESSONS

Effective imaging techniques and differential diagnosis of venous LMS is vital and should be considered for patients with chronic thrombosis presenting with normal laboratory results.

Primary leiomyosarcoma is a rare cause of femoral triangle mass: A case report

OBJECTIVES

Primary leiomyosarcoma in the femoral vein is an extremely rare vascular disorder and is often misdiagnosed. In order to improve the knowledge and treatment of this disease, a case of leiomyosarcoma in the femoral vein was reported.

METHODS

We report the case of a 58-year-old woman with a leiomyosarcoma of the femoral vein and treated successfully by surgical resection. After surgery, no recurrence had been noted follow-up.Subsequently, we reviewed information derived from 31 previously published cases from 1954 to 2019.

RESULTS

A total of 31 patients diagnosed with femoral vein leiomyosarcoma were presented in previous studies; in all of these patients, 14 (45.2%, 14/31) patients were men. Of these, the median age was 51.6 years old (ranging from 3 to 84).

CONCLUSIONS

Complete resection with adjuvant chemotherapeutic was the main strategy to treat the disease. Prognosis remains poor if metastasis was present, especially pulmonary metastasis.

Challenges in diagnosing aortic leiomyosarcoma post endovascular repair of abdominal aortic aneurysm

Primary aortic tumors after endovascular aortic repair are rarely reported in the literature. Here, we report an elderly male with abdominal aortic leiomyosarcomas (LMS) after an endovascular aneurysm repair in 2012 for a 5-cm symptomatic abdominal aortic aneurysm using an Endurant II aortic stent graft (Medtronic, Minneapolis, Minn). The autopsy confirmed the aortic LMS after the patient rapidly deteriorated and succumbed to death. The vascular LMS are rapidly progressive and diagnostically challenging malignant soft tissue tumors with poor prognosis, which necessitates a strong clinical suspicion and attentiveness to radiologic signs for prompt diagnosis.

Successful Resection of a Retrohepatic Inferior Vena Cava Primary Leiomyosarcoma with Atrial Thrombus Extension in a 30-Week Pregnant Woman

Leiomyosarcomas are an uncommon malignant subset of tumors accounting for approximately 20% of soft tissue sarcomas. Primary vascular leiomyosarcomas (PVLs) are a rare subset of leiomyosarcomas that may originate in the arterial or venous circulation but most commonly affect the inferior vena cava (IVC). PVLs more commonly affect women to men in a 2:1 ratio and most frequently occur in the fourth to sixth decades of life. Few reports have described this infrequent pathologic state in the setting of advanced pregnancy. Presented is a case of a 44-year-old 30-week pregnant woman who presented with a PVL of the retrohepatic IVC, which was complicated by occlusion of the IVC and tumor thrombus extension into the hepatic veins and right atrium. Herein, we describe our multidisciplinary management of this rare problem with successful surgical resection of her tumor and IVC reconstruction.

Primary iliocaval leiomyosarcomas: The path beyond surgery

INTRODUCTION

Iliocaval leiomyosarcoma (ICLM) is a rare and aggressive form of sarcoma within the retroperitoneum. Surgery is the mainstay of treatment, with no consensus on the benefit of chemoradiotherapy in the neo/adjuvant setting. This study aims to describe the natural history of a chemotherapy-naïve ICLM treated in a tertiary cancer centre and to explore potential directions to improve oncological outcome.

MATERIALS AND METHODS

A prospective database was used to identify patient demographics, clinicopathological variables and oncological outcomes in 30 patients who underwent surgical resection in our institution for primary non-metastatic ICLM between 2003 and 2018.

RESULTS

There was no 90-day mortality. With a median follow-up time of 70.0 months (95% CI 52.6-87.4), 5/30 patients (16.7%) developed local recurrence while 11/30 (36.7%) developed distant metastatic disease. 1 patient (3.3%) developed both local and distant recurrence. Median overall survival of our cohort was 41.0 months (95% CI 33.6-48.4) and 5-year overall survival rate was 32.1%. Multivariate survival analysis using the Cox proportional hazard model identified tumour grade and blood loss of more than 600 mL as key prognostic factors in our model.

CONCLUSION

Management of ICLM should be centralised in high-volume sarcoma centres with expertise in the management of retroperitoneal sarcomas. Integration of tumour biology with a concerted effort to conduct conclusive multi-centre phase III in histological and molecularly defined sarcoma subgroups is necessary to improve patient outcome. We eagerly await the results of STRASS 2 study to gain more insights to the efficacy of neoadjuvant chemotherapy on patient prognosis.

Two-stage combined treatment of leiomyosarcoma of iliac vein using robotic surgery

Vascular leiomyosarcoma is a rare tumor originating from the vascular smooth muscle cells. Leiomyosarcomas of the external iliac vein are extremely rare. Only single observations of this tumor are reported. We describe a 48-year-old woman who underwent a two-step combined treatment: robot-assisted removal of the extraperitoneal tumor and removal of the lower part of the tumor from the open femoral approach. There have been no signs of tumor recurrence during the 34-month follow-up period.

[LEIOMYOSARCOMA ARISING FROM THE RENAL VEIN]

A 47-year-old female presented to a clinic complaining of right back pain. A CT scan revealed a right retroperitoneal mass and she was referred to our department for further evaluation. Contrast-enhanced CT and MRI revealed a right retroperitoneal mass (6 cm) in the hilum of the right kidney that invaded the right renal vein and inferior vena cava (IVC). Suspecting a tumor arising from retroperitoneal tissues involving the right renal vein and IVC, the decision was made to excise the tumor with the right kidney, renal vein, and a portion of the IVC. The histologic findings indicated that the tumor was a leiomyosarcoma originating from the renal vein wall. The tumor cells were spindle-shaped and stained positive for desmin, caldesmon and HHF35. The post-operative course was uneventful and she was recurrence-free 20 months after surgery. In addition to presenting a case of a leiomyosarcoma of the renal vein, a short review of the literature is provided.

Primary External Iliac Vein Leiomyosarcoma

Leiomyosarcomas of vascular origin are uncommon. They arise from the smooth muscles of tunica media of major blood vessels. Most of the cases are present in women. We report one such case of external iliac vein leiomyosarcoma in a 77-year-old female and discuss the clinical, radiological, and histopathological findings and the available treatment options.

Resection of retroperitoneal sarcoma en-bloc with inferior vena cava: 20 year outcomes of a single institution

BACKGROUND

Margin negative resection offers the best chance of long-term survival in retroperitoneal sarcoma (RPS). En-bloc resection of adjacent structures, including the inferior vena cava (IVC), is often required to achieve negative margins. We review our 20-year experience of en-bloc IVC and RPS resection.

METHODS

Retrospective review of patients with RPS resection involving the IVC were matched 1:3 by age and histology to RPS without IVC resection. Prognostic factors for overall survival (OS) and disease free survival (DFS) were assessed.

RESULTS

Thirty-two patients underwent RPS resection en-bloc with IVC. They were matched with 96 cases of RPS without IVC resection. Median OS of 59 months and DFS 18 months in IVC resection group was comparable to RPS resection without vascular involvement: median OS 65 months, DFS 18 months (P = 0.519, P = 0.604). On multivariate analyses, R2 margin (OS: HR = 6.52 [95%CI: 1.18-36.09], P = 0.032) was associated with inferior OS. R2 margin and increased number of organs resected (DFS: HR = 5.07, [1.15-22.27], P = 0.031, HR = 1.28 [1.01-1.62], P = 0.014) were associated with inferior DFS. Reconstructions included graft (n = 19, 59%), patch (n = 4, 13%), primary repair (n = 6, 19%), and ligation (n = 4, 13%).

CONCLUSIONS

RPS resection en-bloc with IVC can achieve equivalent rates of DFS and OS to patients without vascular involvement.

Non-canonical WNT6/WNT10A signal factor expression in EBV+ post-transplant smooth muscle tumors

Post-transplant smooth muscle tumors (PTSMTs) are rare mesenchymal neoplasms which occur after solid organ or haematopoietic stem cell transplantation. PTSMT typically consist of Epstein–Barr-virus (EBV)+ smooth muscle-like cells and show an intermediate malignancy. Their main occurrences are visceral organs, especially the liver, but intracranial appearances are described and associated with a poor prognosis. EBV drives the growth of PTSMT; however, the underlying molecular mechanisms still remain unclear. Gene expression analysis of a set of morphologically similar tumors (leiomyomas, leiomyosarcomas, angioleiomyomas and endothelial haemangiomas) from patients without immunosuppression or EBV-association was performed. Our findings indicate that PTSMT’s growth is driven by two factors of the wingless-type protein family: WNT6 and WNT10A. We are first to report that in PTSMTs, a non-canonical activation of WNT, independent of beta-catenin, drives tumor cell proliferation via MTOR/AKT1, MYC and Cyclin D2.

Pulsed Dye Laser Treatment Combined with Oral Minocycline Reduces Recurrence Rate of Rosacea

Background

The recurrence rate of rosacea was not known very well, but has been reported as 60% in 6 months after withdrawal of the drug. It is not known which treatment can reduce relapses of rosacea effectively.

Objective

The objective was to identify whether 595 nm-pulsed dye laser (PDL) treatment reduced recurrence rate among rosacea patients who were treated with oral minocycline.

Methods

One hundred and seven Korean patients with rosacea who started treatment with oral minocycline (100 mg/d) with or without PDL (2∼4 sessions) were evaluated retrospectively. The recurrence rate was estimated using the Kaplan-Meier method, and difference was evaluated using the log-rank test. Cox proportional hazards model was used to estimate hazard ratios and 95% confidence intervals (CIs) of risk factors for the recurrence of rosacea.

Results

The recurrence-free survival analysis revealed that the group with oral minocycline plus PDL was significantly different compared with the group with oral minocycline alone (p=0.011). Cox proportional hazards model showed that the combined use of PDL with oral minocycline appeared to be a significant protective factor for the hazard of recurrence of rosacea (hazard ratio, 0.492; 95% CI, 0.257∼0.941; p=0.032).

Conclusion

PDL can be used added to oral minocycline to reduce relapses among rosacea patients who are undergoing oral minocycline treatment.