Intravenous leiomyomatosis: Case series and review of the literature

Pathological characteristics and clinical prognostic analysis of intravenous leiomyomatosis: a retrospective study of 43 cases

Objective

To analyze the clinicopathological features and prognostic factors of intravenous Leiomyomatosis (IVL), a rare yet recurrent disease.

Methods

This retrospective observational study enrolled 43 patients with pathologically confirmed IVL. Clinicopathological data were collected and reviewed. Univariate analyses were performed to identify prognostic factors for IVL recurrence.

Results

Clinical manifestations included increased menstrual flow (12/43), prolonged menstrual periods (18/43), pelvic mass (15/43), abdominal pain (8/43), or no symptoms (9/43). Histopathologically, tumor cells were predominantly located in the blood vessels of the uterine muscle wall and surrounding blood vessels. The tumor were composed of benign smooth muscle cells arranged in strips or bundles. Immunohistochemistry revealed that tumor cells were positive for SMA (43/43), Desmin (42/43), and Caldesmon (40/43). Incomplete resection of the lesions was identified as a risk factor for postoperative recurrence of IVL (P < 0.05). Age, menopause status, gravidity, parity, maximum diameter of IVL, uterine leiomyomas, involvement of uterine/extrauterine blood vessels, surgical methods, Ki-67 index, and mitotic figures were not associated with postoperative recurrence of IVL (P > 0.05).

Conclusion

IVL is a rare form of leiomyoma with potential for malignancy. Complete resection of the lesion should be performed whenever possible to improve patient prognosis.

Analysis of risk factors for post-operative recurrence or progression of intravenous leiomyomatosis

OBJECTIVE

To analyse the risk factors for post-operative recurrence or progression of intravenous leiomyomatosis and explore the impact of different treatment strategies on patient prognosis.

METHODS

Patients with intravenous leiomyomatosis who underwent surgery from January 2011 to December 2020 and who were followed for ≥3 months were included. The primary endpoint was recurrence (for patients with complete resection) or progression (for patients with incomplete resection). Kaplan-Meier survival analysis was used to analyse the factors affecting recurrence.

RESULTS

A total of 114 patients were included. The median age was 45 years old (range 24-58). The tumors were confined to the uterus and para-uterine vessels in 48 cases (42.1%), while in 66 cases (57.9%) it involved large vessels (iliac vein or genital vein and/or proximal large veins). The median follow-up time was 24 months (range 3-132). Twenty-nine patients (25.4%) had recurrence or progression. The median recurrence or progression time was 16 months (range 3-60). Incomplete tumor resection (p=0.019), involvement of the iliac vein or genital vein (p=0.042), involvement of the inferior vena cava (p=0.025), and size of the pelvic tumor ≥15 cm (p=0.034) were risk factors for recurrence and progression. For intravenous leiomyomatosis confined to the uterus or para-uterine vessels, no post-operative recurrence after hysterectomy and bilateral oophorectomy occurred in this cohort. Compared with hysterectomy and bilateral oophorectomy, the risk of recurrence after tumorectomy (with the uterus and ovaries retained) was significantly greater (p=0.009), while the risk of recurrence after hysterectomy was not significantly increased (p=0.058). For intravenous leiomyomatosis involving the iliac vein/genital vein and the proximal veins, post-operative aromatase inhibitor treatment (p=0.89) and two-stage surgery (p=0.86) were not related to recurrence in patients with complete tumor resection.

CONCLUSION

Incomplete tumor resection, extent of tumor lesions and size of the pelvic tumor were risk factors for post-operative recurrence and progression of intravenous leiomyomatosis.

Unraveling the challenges of intravenous leiomyomatosis: a retrospective analysis of 11 cases

OBJECTIVE

This study provides a concise overview of diagnostic and treatment strategies for intravenous leiomyomatosis (IVL), a rare disease with nonspecific clinical manifestations, based on cases from a tertiary referral hospital in China.

METHODS

We retrospectively analyzed 11 premenopausal patients with confirmed IVL between 2018 and 2022. Clinical data from Ultrasound, Enhanced CT, and MRI were studied, along with surgical details, postoperative pathology, and follow-up information.

RESULTS

Premenopausal patients showed no disease-specific symptoms, with 90.9% having a history of gynecological or obstetric surgery, and 72.7% having prior uterine fibroids. Cardiac involvement was evident in two cases, with echocardiography detecting abnormal floating masses from the inferior vena cava. Pelvic ultrasound indicated leiomyoma in 90.9% of cases, with ≥ 50 mm size. Surgery was the primary treatment, and lesions above the internal iliac vein resulted in significantly higher intraoperative blood loss (median 1300 ml vs. 50 ml, p = 0.005) and longer hospital stays (median 10 days vs. 4 days, p = 0.026). Three patients with lesions above the inferior vena cava required combined surgery with cardiac specialists. Recurrence occurred in 2 out of 11 patients with incomplete lesion resection.

CONCLUSIONS

IVL mainly affects premenopausal women with uterine masses, primarily in the pelvic cavity (Stage I). Pelvic ultrasound aids early screening, while Enhanced CT or MR assists in diagnosing and assessing venous lesions. Complete resection is crucial to prevent recurrence. Lesions invading the internal iliac vein and above pose higher risks during surgery. A multidisciplinary team approach is essential for patients with lesions above the inferior vena cava, with simultaneous surgery as a potential treatment option.

Magnetic resonance imaging findings of intravascular leiomyomatosis of the uterus: a case report

Background

Intravascular leiomyomatosis (IVL) is often a non-malignant condition that grows inside the blood vessels and does not invade surrounding tissues. However, its presence within the blood vessels can lead to obstructions. The majority of IVL cases manifest symptoms related to blockage.

Case presentation

We present a case of a 50-year-old female patient who was referred to our institution due to the presence of a common non-cancerous tumor in the uterus, known as a benign uterine leiomyoma. The tumor was identified during an ultrasound examination during a routine physical examination. Postoperative pathology established the existence of intrapelvic IVL.

Conclusion

Intrapelvic IVL often not present with complications when it is confined to the pelvic cavity. Furthermore, the imaging features of intrapelvic IVL resemble those of typical benign uterine leiomyomas. This can often result in the clinical misdiagnosis of the tumor as a typical benign uterine leiomyoma.

Intravascular leiomyomatosis with cardiac and pelvic involvement in a postmenopausal woman: A case report of multidisciplinary team management

Intravascular leiomyomatosis (IVL) is a rare benign condition in which a leiomyoma, originating from the uterus, propagates through the pelvic venous system and occasionally extends into the inferior vena cava (IVC), occasionally reaching the heart. Despite its low incidence and benign nature, IVL can lead to life-threatening obstructions in the right heart's outflow tract, potentially resulting in sudden death. In this article, we present a case of a 72-year-old postmenopausal patient with IVL, who initially presented with palpitations. The diagnosis was made through echocardiography and a computerized tomography (CT) scan, revealing a tumor that extended from the uterus through the IVC and into the right ventricle. The patient was managed by a multidisciplinary team of gynecologists and cardiothoracic surgeons, who performed a single-stage surgical removal of a tumor 25 cm long. The pathological report confirmed the diagnosis of IVL. Postoperative follow-up is crucial, as IVL recurs in up to 30% of cases. This article's objective is to provide a clinical illustration of this exceedingly rare condition, with fewer than 300 reported cases, and to offer a comprehensive overview of IVL, including its clinical presentation, diagnosis, treatment, and outcomes.

Intravenous leiomyomatosis of the uterus: Preoperative and intraoperative assessment

OBJECTIVE

To assess factors influencing preoperative diagnosis and hemorrhage during surgery with uterine intravenous leiomyomatosis.

METHODS

This retrospective single-institution study used univariate analysis and multivariate models to investigate potential factors contributing to preoperative diagnosis and hemorrhage during surgery associated with intravenous leiomyomatosis in 135 patients from January 2012 to April 2022. Risk factors for disease recurrence were also investigated. The SPSS statistical analysis package was used for data analysis.

RESULTS

Previous myomectomy or fibroid ablation and tumor location on color Doppler were related to preoperative diagnosis (P = 0.031 and P = 0.003, respectively). Multivariate regression analysis demonstrated that lesions extending to the broad ligament were the only factors affecting preoperative diagnosis (odds ratio [OR] 5.383, 95% confidence interval [CI] 1.49-19.47). Univariate analysis showed that previous myomectomy or fibroid ablation (P = 0.017), tumor location (P = 0.027), and parauterine involvement (P = 0.014) were associated with intraoperative hemorrhage. Parauterine involvement was an independent risk factor for increased bleeding (OR 1.36, 95% CI 1.14-3.92). Six patients (4.4%) relapsed. The present study demonstrated that age (P = 0.031) and surgical type (P < 0.001) might be associated with disease recurrence.

CONCLUSIONS

Treatment emphasis should focus on lesions extending to the broad ligament. Intraoperative bleeding associated with parauterine involvement should be stopped as effectively as possible.

Surgical management of intravenous leiomyomatosis with intracardiac extension

Intravenous leiomyomatosis is a rare smooth muscle tumor that is associated with uterine leiomyomas. Intravenous leiomyomatosis often presents with nonspecific abdominal and cardiac symptoms, making the diagnosis difficult. We present a comprehensive review of a case of a 52-year-old woman with intravenous leiomyomatosis with intracardiac extension, who was successfully treated with complete surgical resection.

Tumor in Transit: Intracardiac Leiomyomatosis

Intravenous leiomyoma is a rare condition that occurs when there is a vascular invasion of a pre-existing uterine leiomyoma. The tumor can metastasize to structures such as the heart and lungs. We discuss a case of metastasis to the heart resulting in severe tricuspid regurgitation. Surgical intervention is the primary modality; usually a staged approach involving cardiac surgery along with abdominal and/or pelvic surgery. We want to highlight the importance of fully investigating right-sided cardiac masses. While there are common etiologies for these masses, one must maintain a high degree of suspicion for an intravenous leiomyoma, especially if a female has certain risk factors such as a prior history of fibroids or a hysterectomy. We also stress the importance of a multi-disciplinary team approach when providing care to these patients, along with reviewing all modalities of imaging.

Intravascular leiomyomatosis with extension to the inferior vena cava

Intravascular leiomyomatosis (IVL) is a rare benign smooth muscle neoplasm growing within the pelvic venous system, often with caval and intracardiac extension. It frequently coexists with uterine leiomyomas or occurs in women with a history of myomectomy or hysterectomy. IVL is often asymptomatic until intracardiac extension occurs, and carries a risk of sudden death, necessitating timely diagnosis and management. We present a case of IVL diagnosed on hysterectomy specimen with extension to the inferior vena cava found on follow-up imaging. The patient underwent complete resection with multidisciplinary involvement of Gynaecological Oncology and Vascular Surgery and remains disease free following 12 months of follow-up.

Imaging diagnosis of intravenous leiomyomatosis: an institutional experience

AIM

To review and summarise the clinical and imaging characteristics of intravenous leiomyomatosis (IVL), a rare smooth muscle tumour originating from the uterus.

MATERIALS AND METHODS

Twenty-seven patients with a histopathological diagnosis of IVL who underwent surgery were reviewed retrospectively. All patients underwent pelvic ultrasonography, inferior vena cava (IVC) ultrasonography, and echocardiography before surgery. Computed tomography (CT) with contrast enhancement was performed in patients with extrapelvic IVL. Some patients underwent pelvic magnetic resonance imaging (MRI).

RESULTS

Mean age was 44.81 years. Clinical symptoms were non-specific. IVL was intrapelvic in seven patients and extrapelvic in 20. Preoperative pelvic ultrasonography missed the diagnosis in 85.7% of patients with intrapelvic IVL. Pelvic MRI was useful to evaluate the parauterine vessels. Incidence of cardiac involvement was 59.26%. Echocardiography showed a highly mobile sessile mass in the right atrium with moderate-to-low echogenicity that originates from the IVC. Ninety per cent of extrapelvic lesions showed unilateral growth. The most common growth pattern was via the right uterine vein-internal iliac vein-IVC pathway.

CONCLUSION

The clinical symptoms of IVL are non-specific. For patients with intrapelvic IVL, early diagnosis is difficult. Pelvic ultrasound should focus on the parauterine vessels, the iliac and ovarian veins should be explored carefully. MRI has obvious advantages in evaluating parauterine vessel involvement, which is helpful for early diagnosis. For patients with extrapelvic IVL, CT should be performed before surgery as part of a comprehensive evaluation. IVC ultrasonography and echocardiography are recommended when IVL is highly suspected.

Intracardiac Leiomyomatosis Arising from a Uterine Leiomyoma - A Rare Case Requiring a Multidisciplinary Laparotomy-Thoracotomy Approach

A 37-year-old lady, when being evaluated in gynecology for pain in the abdomen, was found to have a pelvic mass suspicious of ovarian cancer with markers negative. There was an ovarian vein thrombosis extending to the right atrium in the contrast-enhanced computed tomography scan. A fluorodeoxyglucose positron emission tomography-computed tomography ruled out any other lesions. The patient underwent surgery under general anesthesia with transesophageal echocardiography to monitor the atrial thrombus. Intraoperatively, a retroperitoneal mass is seen arising from the right adnexal region of the uterus extending to the lumbar area. After the hysterectomy, bilateral salpingo-oophorectomy, tumor resection, and baring and looping of the retroperitoneal vessels, a sternotomy was done, and she was put on cardiopulmonary bypass. The tumor thrombus had two limbs both arising from the mass, one through the ovarian and the second through the iliac veins and joining together inside the inferior vena cava (IVC). With the excision of the ovarian vein at its junction, atrial incision, and incisions over the iliac veins and IVC, the thrombus was removed completely in a single sitting. Final histopathology revealed intravenous leiomyomatosis and no malignancy. We report this case as a rare disease, with both ovarian and iliac thrombus being a further rarity and a multidepartment joint effort with a successful outcome.

Review of uterine fibroids: imaging of typical and atypical features, variants, and mimics with emphasis on workup and FIGO classification

Uterine fibroids are the most common gynecologic neoplasm. Although non-degenerated fibroids are easily identifiable on imaging, degenerated fibroids, fibroid variants, and fibroids with unusual growth patterns can constitute a diagnostic dilemma. Identification of these abnormal morphologic features can alter the diagnosis of presumed uterine fibroids and hence change management plans. This article reviews the typical and atypical radiologic imaging features of uterine fibroids, with an emphasis on the pitfalls, mimics, and radiologically identifiable features that can alter clinical management plans.