Leiomyosarcoma of the inferior vena cava: analysis and search of world literature on 141 patients and report of three new cases

Incidentally Diagnosed Extraluminal Leiomyosarcoma of Infrarenal Inferior Vena Cava: A Case Report and Literature Review from a Radiologist's Perspective

Background

Vascular leiomyosarcoma is a rare but most common vascular tumor of the inferior vena cava.

Case presentation

We present the case of an incidentally diagnosed extraluminal leiomyosarcoma of the inferior vena cava in a 62 year old patient who presented with abdominal pain following blunt trauma. Ultrasonography showed a lobulated hypoechoic lesion in the upper abdomen. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a circumscribed lobulated near homogeneously enhancing retroperitoneal lesion in anterior relation to the infrarenal inferior vena cava, right paramedian in location with imperceptible vena caval lumen at the site of maximum contact. In positron emission tomography (PET) CT the lesion showed mild fluorodeoxyglucose (FDG) uptake with no distant metastases. CT guided biopsy with immunohistochemical analysis showed leiomyosarcoma. Patient underwent surgical resection with inferior vena cava reconstruction.

Conclusions

Leiomyosarcoma of the inferior vena cava is a rare tumor of vascular origin. Imaging plays an imperative role in the diagnosis and preoperative evaluation. This article also provides a comprehensive literature review of the radiological features of inferior vena caval leiomyosarcoma that would aid in optimal preoperative characterization and evaluation.

Leiomyosarcoma of the inferior vena cava. Our experience and a review of the literature

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignant tumor, accounting for 2% of all LMSs. Less than 400 cases have been reported in literature. Computed tomography (CT) is the most accurate imaging method in assessing the location of the tumor within the IVC and magnetic resonance imaging (MRI) accurately identifies its extent and the potential for surgical resection. We present the case of a patient with inferior vena cava leiomyosarcoma (IVCL), for whom the pathological diagnosis was different from the initially expected one, the tumor appearance on pre-operative imaging mimicking renal cell carcinoma. The intraoperative difficulty of approaching renal hilum and IVC was a factor suggesting the vascular origin of the tumor, which was confirmed at pathological analysis. The extensive defect in the IVC after tumor excision led to the decision of complete transverse suturing of IVC, as significant collateral venous circulation was already present. Because IVCL is a rare disease, there is scarce data regarding the prognosis and treatment options. Long-term survival depends on the extent of the surgery. The need of vascular reconstruction is not always mandatory. Despite high recurrence rates, no consensus regarding adjuvant treatment exists yet. A multidisciplinary approach including surgical oncologists and vascular surgeons is mandatory to achieve the best patient outcomes. Perioperative planning, coordination and adherence to oncological techniques are critical.

Dyspnea due to an uncommon vascular tumor: leiomyosarcoma of the infrahepatic vena cava inferior

Background

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignancy that originated from the smooth muscle tissue of the vascular wall. Diagnoses, as well as, treatment of the disease are still challenging and to date, a radical surgical resection of the tumor is the only curative approach.

Case report

We report on the case of a 49-year old male patient who presented with suddenly experienced dyspnea. Besides bilateral pulmonary arterial embolism, a lesion close to the head of the pancreas was found using CT scan, infiltrating the infrahepatic IVC. Percutaneous ultrasound-guided biopsy revealed a low-grade LMS. Intraoperatively, a tumor of the IVC was observed without infiltration of surrounding organs or distant metastases. Consequently, the tumor was removed successfully, by en-bloc resection including prosthetic graft placement of the IVC. Histological workup revealed a completely resected (R0) moderately differentiated LMS of the IVC.

Conclusion

LMS of the infrahepatic IVC is an uncommon tumor, which may present with dyspnea as its first clinical sign. Patients benefit from radical tumor resection. However, due to the poor prognosis of vascular LMS, a careful follow-up is mandatory.

Tumor in the veins: an abdominal perspective with an emphasis on CT and MR imaging

Endovenous tumor thrombus in abdomen should be accurately diagnosed as it is a significant finding that may change medical and surgical treatment approaches. As some underlying reasons for endovenous tumor thrombi are relatively rare and imaging findings may be quite subtle, they can be easily overlooked which may have important clinical consequences. In this paper, we described the various imaging aspects of endovenous tumor thrombi originating from various tumor types in different venous structures of the abdomen.

Leiomyosarcoma of the inferior vena cava presenting as deep venous thrombosis; case report

Primary tumors arising from the inferior vena cava are extremely rare, leiomyosarcoma is the most common one arising from the smooth muscle cells in the media of the wall of the vena cava. A 42-year-old lady had epigastric pain and back pain for 4 months with signs of deep vein thrombosis of the right lower limb. CT-scan showed a mass related to the inferior vena cava which was proved by histopathological examination to be leiomyosarcoma of the inferior vena cava. A multidisciplinary team is required for the diagnosis and management of tumors the vena cava. Long term follow-up is recommended.

Inferior vena cava leiomyosarcoma in an octogenerian

Inferior Vena Cava (IVC) leiomyosarcoma (LM) is a rare malignancy of mesenchymal origin with an incidence of 1/100,000. We present an 82-year-old lady with a past history of open cholecystectomy who presented with a large indeterminate mass on abdominal imaging. Open resection of the mass was performed and histology with immunohistochemical staining revealed leiomyosarcoma. She received adjuvant radiotherapy and remained disease free 4 years after.

The Use of Autologous Peritoneum for Complete Caval Replacement Following Resection of Major Intra-abdominal Malignancies

OBJECTIVE

Assessment of a simple layer peritoneal tube used as an autogenous inferior vena cava replacement.

BACKGROUND

Extensive en-bloc multivisceral resection including major vessels is effective in selected abdominal malignancies, but the need for vascular reconstruction represents a surgical challenge. We describe the use of autologous peritoneum for caval replacement.

METHODS

Autogenous parietal peritoneum without fascial backing was harvested and tubularized to replace the inferior vena cava (IVC) in four patients with complex abdominal tumors. Surgical morbidity was evaluated using the Clavien-Dindo classification, and graft patency was systematically evaluated with ultrasound.

RESULTS

All four patients had multiorgan resections for malignancies involving the retro-hepatic IVC, and they all required the replacement of infrarenal and suprarenal IVC segments. Additionally, all four required a right nephrectomy, two had a combined major hepatectomy, and one patient needed a veno-venous bypass. All had an R0 resection. A clinical follow-up took place between 5 and 11 months after surgery for each patient. Four-month graft patency was confirmed by ultra-sound and TDM with no sign of disease recurrence.

CONCLUSIONS

Autologous peritoneum without fascial backing is a good and safe option for circumferential replacement of IVC after extensive en-bloc tumor resection with IVC involvement.

Can the Right Kidney be Salvaged in the Surgical Management of Leiomyosarcoma of the Inferior Vena Cava-a Rare Case Report

Primary leiomyosarcoma is rare malignant tumour arising from the smooth muscles and can appear at any site where smooth muscle is present. It is more common in the peripheral vessels and has predilection for the female sex. We here report a rare case of leiomyosarcoma involving the segment I & II of inferior vena cava with extension into the renal veins in a 70 year old male patient. Midline transperitoneal approach was taken to excise the tumour along with the vessel wall with anastomosis between the right renal vein and the infrarenal inferior vena cava with a reversed great saphenous vein graft thereby salvaging the right kidney.

Surgical resection and inferior vena cava reconstruction for treatment of the malignant tumor: technical success and outcomes

OBJECTIVE

The purpose of this study was to review patients who underwent inferior vena cava (IVC) resection with concomitant malignant tumor resection and to consider the operative procedures and the outcomes.

MATERIALS AND METHODS

Between 2000 and 2012, 41 patients underwent resection of malignant tumors concomitant with surgical resection of the IVC at our institute. The records of these patients were retrospectively reviewed.

RESULTS

Primary tumor resections included nephrectomy, hepatectomy, retroperitoneal tumor extirpation, lymph node dissection, and pancreaticoduodenectomy. The IVC interventions were partial resection in 23 patients and total resection in 18 patients. Four patients underwent IVC replacement. Operation-related complications included pulmonary embolism, acute myocardial infarction, deep vein thrombosis, leg edema and temporary hemodialysis. There were no operative deaths. The mean follow-up period was 24.9 months (range: 2-98 months). The prognosis depended on the type and stage of the tumor.

CONCLUSION

Resection and reconstruction of the IVC can be performed safely if the preoperative evaluations and surgical procedures are performed properly. The IVC resection without reconstruction was permissive if the IVC was completely obstructed preoperatively, but it may also be considered in cases where the IVC is not completely obstructed.

Surgical treatment for an invasive leiomyosarcoma of the inferior vena cava

A 49-year-old woman presented with right lumbar pain and edema in both legs. Computed tomography showed a large low attenuated mass around and in the S7 segment of the liver involving the right kidney and multiple enlarged mesenteric lymph nodes. There were multiple variably sized discrete nodules in both lungs. Cavography showed subtotal occlusion of the inferior vena cava (IVC). She was successfully treated by wide resection and IVC reconstruction with partial cardiopulmonary bypass and metastasectomy.

Renal leiomyosarcoma

Leiomyosarcoma (LMS) is a rare malignant tumor of smooth muscle origin that generally stems from soft tissues and uterine tissue. Although, a small percentage of these may originate from the smooth muscle or vessel walls, most of which are of venous origin. Renal leiomyosarcomas may arise from the smooth muscle fibers of renal pelvis, renal capsule or renal vessels, last one is the most frequent. We report a case of renal LMS that could be originated in the renal capsule.

Leiomyosarcoma of the Inferior Vena Cava - Radical Resection, Vascular Reconstruction and Challenges: A Case Report and Review of Relevant Literature

Leiomyosarcomas of the inferior Vena Cava (IVC) are rare soft tissue sarcomas accounting for only 0.5% of all soft tissue sarcomas in adults with fewer than 300 cases reported. Extraluminal tumor growth along the adventitia of the IVC seems to be the common presentation. Intraluminal tumor growth is rare. The origin of the tumor is divided into three levels in relation to the hepatic and renal veins. The presentations and surgical modalities vary accordingly. Retroperitoneal tumors are often not diagnosed until the disease is at an advanced stage with large tumor growth and involvement of surrounding structures. This is partly because of the nonspecific clinical presentation as well as absence of early symptoms. Most patients present with abdominal or flank pain. Symptoms vary according to the dimensions of the tumor, growth pattern and localization of the tumor. Radical en bloc resection of the affected venous segment remains the only therapeutic option associated with prolonged survival. The goals of surgical management of these tumors include the achievement of local tumor control, maintenance of caval flow, and the prevention of recurrence. The involvement of renal or hepatic veins determines the strategy for vascular reconstruction. Reconstruction of the IVC is not always required, because gradual occlusion of the IVC allows the development of venous collaterals. However, when pararenal leiomyosarcoma of the IVC is present, reconstruction of the IVC and the renal vein is necessary to prevent transient or permanent renal dysfunction. Recent study has shown that radical surgery combined with adjuvant multimodal therapy has improved the cumulative survival rate. We report a case of IVC leiomyosarcoma in a young healthy woman along with details of its diagnostic workup and discussion of the surgical options and reconstruction of caval continuity.

Resection and reconstruction of the inferior vena cava for neoplasms

AIM: To evaluate the results of an aggressive surgical approach of resection and reconstruction of the inferior vena cava (IVC).

METHODS: The approach to caval resection depends on the extent and location of tumor involvement. The supra- and infra-hepatic portion of the IVC was dissected and taped. Left and right renal veins were also taped to control the bleeding. In 12 of the cases with partial tangential resection of the IVC, the flow was reduced to less than 40% so that the vein was primarily closed with a running suture. In 3 of the cases, the lumen of the vein was significantly reduced, requiring the use of a polytetrafluoroethylene (PTFE) patch. In 2 of the cases with segmental resection of the IVC, a PTFE prosthesis was used and in 1 case, the IVC was resected without reconstruction due to shunting the blood through the azygos and hemiazygos veins.

RESULTS: The mean operation time was 266 min (230-310 min) with an average intraoperative blood loss of 300 mL (200-2000 mL). The patients stayed in intensive care unit for 1.8 d (1-3 d). Mean hospital stay was 9 d (7-15 d). Twelve patients (66.7%) had no complications and 6 patients (33.3%) had the following complications: acute bleeding in 2 patients; bile leak in 2 patients; intra abdominal abscess in 1 patient; pulmonary embolism in 2 patients; and partial thrombosis of the patch in 1 patient. General complications such as pneumonia, pleural effusion and cardiac arrest were observed in the same group of patients. In all but 1 case, the complications were transient and successfully controlled. The mortality rate was 11.1% (n = 2). One patient died due to cardiac arrest and pulmonary embolism in the operation room and the second one died 2 d after surgery due to coagulopathy. With a median follow-up of 24 mo, 5 (27.8%) patients died of tumor recurrence and 11 (61.1%) are still alive, but three of them have a recurrence on computed tomography.

CONCLUSION: There are a variety of options for reconstruction after resection of the IVC that offers a higher resectable rate and better prognosis in selected cases.

Leiomyosarcoma of inferior vena cava involving bilateral renal veins: Surgical challenges and reconstruction with upfront saphenous vein interposition graft for left renal vein outflow

Leiomyosarcoma of inferior vena cava (IVC) involving bilateral renal veins presents a surgical challenge. Herein, we report the successful management of two such cases using restoration of left renal venous outflow by saphenous vein interposition graft as first step of surgery. Then radical resection of tumor and right kidney was done. IVC was lastly reconstructed using Gore-Tex graft. This report highlights the surgical challenges to ensure radical resection. Furthermore, the importance of restoring left renal outflow in presence of concomitant right nephrectomy is discussed. Both the patients were disease free at six months with no loss of left renal glomerular filtration rate.

Pancreatic and multiorgan resection with inferior vena cava reconstruction for retroperitoneal leiomyosarcoma

BACKGROUND

Inferior vena cava (IVC) leiomyosarcoma is a rare tumor of smooth muscle origin. It is often large by the time of diagnosis and may involve adjacent organs. A margin-free resection may be curative, but the resection must involve the tumor en bloc with the affected segment of vena cava and locally involved organs. IVC resection often requires vascular reconstruction, which can be done with prosthetic graft.

CASE PRESENTATION

We describe a 39-year-old man with an IVC leiomyosarcoma that involved the adrenal gland, distal pancreas, and blood supply to the spleen and left kidney. Tumor excision involved en bloc resection of all involved organs with reimplantation of the right renal vein and reconstruction of the IVC with a polytetrafluoroethylene graft. The patient recovered without renal insufficiency, graft infection, or other complications. Follow-up abdominal imaging at 1 year showed a patent IVC graft and no locally recurrent tumor. Prosthetic graft provides a sufficient diameter and length for replacement conduit in extensive resection of IVC leiomyosarcoma.

CONCLUSION

To our knowledge, this is the first case of resection of an IVC sarcoma with prosthetic graft reconstruction in combination with pancreatic resection. Aggressive surgical resection including vascular reconstruction is warranted for select IVC tumors to achieve a potentially curative outcome.

Leiomyosarcoma of the inferior vena cava: clinical experience with four cases

Background

Leiomyosarcoma of the inferior vena cava is a rare tumor that presents in an insidious manner with non-specific symptoms. Given its rarity, there are no consensus guidelines to its management. The aim of this study was to report the clinical experience in the management of patients presenting to our institution during a 12 year period.

Patients and Methods

Four patients with leiomyosarcomas of the inferior vena cava were managed at our institution during the period reviewed. Patient details were identified through a search of the pathology department computerized database, and case notes were retrospectively reviewed to obtain details of presentation and management.

Results

There were 3 females and 1 male with a mean age of 59 years. All tumors were identified within 2 months of first symptoms. Three of the 4 had localized tumors whilst 1 patient had lung metastases at presentation. The three patients with resectable tumors underwent radical surgical excision of the tumor, and two patients had postoperative radiotherapy. One patient died of recurrence at 7 months, and another at 30 months. The third patient is currently well and disease free at 16 months. The fourth patient with metastatic disease was treated with chemotherapy alone and survived 36 months.

Conclusion

Leiomyosarcoma of the inferior vena cava is an uncommon tumor that presents with non-specific symptoms. At the time of presentation, tumors are usually large and resection is challenging but probably offers the best opportunity for long-term survival.

[Leiomyosarcoma of the inferior vena cava. Review of a rare disease]

Primary sarcomas of the great vessels are rare. Their most common site is the inferior vena cava. We report a primary leiomyosarcoma of a 41 year old female patient localised just below the right renal vein. The resected tumour showed the histological signs of a well differentiated, progesterone positive leiomyosarcoma. The case is discussed on the data of the reviewed literature.

Intravenous Uterine Leiomyosarcomatosis With Intracardial Extension

Uterine leiomyosarcoma is a rare malignant tumor of smooth muscle origin. We describe the case of a 64-year-old female with intravenous uterine leiomyosarcomatosis with the extension of the tumor mass into the inferior vena cava and right atrium. As initial tissue diagnosis of the tumor obtained from the uterine and right atrial masses suggested intravenous leiomyomatosis, surgical resection was carried out using a one-stage procedure via a laparotomy and median sternotomy with cardiopulmonary bypass and circulatory arrest. Subsequent histology revealed uterine leiomyosarcoma with an intravenous spread, which to our knowledge is only the second case that has been described.

[Misdiagnosis of a Leiomyosarcoma of the inferior vena cava as a renal cell carcinoma]

Leiomyosarcoma of the vena cava inferior (VCI) is a rare mesenchymal malignant tumor of the retroperitoneum. About 200 cases have been described in the literature so far. Leiomyosarcomas may resemble other tumors including renal cell carcinoma, adrenal carcinoma, and hepatic adenoma. Thus, misinterpretation of a leiomyosarcoma of the VCI is a common problem. We present a 71-year-old female with a large subhepatic, retroperitoneal tumorous mass which was diagnosed to be a renal cell carcinoma by sonography and computed tomography. After application of magnetic resonance imaging and retrospective analysis of the CT scan, diagnosis could be revised. Laparotomy and en bloc resection of the tumor was performed; histopathological examination confirmed a leiomyosarcoma of the VCI. The postoperative course was unremarkable. Leiomyosarcoma of the VCI may resemble advanced stages of renal cell carcinoma. High-resolution imaging modalities (computed tomography, magnetic resonance imaging) are able to precisely evaluate the typical imaging characteristics of leiomyosarcomas, thus determining correct diagnosis in affected patients. This is essential for successful operative therapy.

Resection of the inferior vena cava for neoplasms with or without prosthetic replacement: a 14-patient series

OBJECTIVE

To review the outcome of resection of the suprarenal or infrarenal inferior vena cava (IVC) and possible indications for prosthetic replacement.

SUMMARY BACKGROUND DATA

Involvement of the IVC has long been considered a limiting factor for curative surgery for advanced tumors because the surgical risks are high and the long-term prognosis is poor. Prosthetic replacement of the IVC is controversial.

METHODS

The authors retrospectively reviewed a 7-year series of 14 patients who underwent en bloc resection including a circumferential segment of the IVC. The tumor was malignant in 12 patients and benign in 2. The resected segment of the IVC was located above the kidneys in eight patients and below in six. Resection was performed without extracorporeal circulation in all patients.

RESULTS

In all but one patient, IVC resection was associated with multivisceral resection, including extended nephrectomy (n = 8), major hepatic resection (n = 3), digestive resection (n = 3), and infrarenal aortic replacement (n = 2). Prosthetic replacement of the IVC was performed in eight patients cases and was more common after resection of a suprarenal (6/8) than an infrarenal segment of the IVC (2/6). One patient died of multiorgan failure. Major complications occurred in 29% of patients. Symptomatic complications of prosthetic replacement occurred in one patient (acute postoperative thrombosis, successfully treated by surgical disobstruction). Graft-related infection was not observed. Marked symptoms of venous obstruction developed in three of the six patients who did not undergo venous replacement. In patients undergoing surgery for malignant disease, the estimated median survival was 37 months and the actuarial survival rate was 67% at 1 year.

CONCLUSION

Multivisceral resection including a segment of IVC is justified to achieve complete extirpation in selected patients with extensive abdominal tumors. Prosthetic replacement of the IVC may be required, particularly in cases of suprarenal resection. It is a safe procedure with a low complication rate and good functional results.

Leiomyosarcoma of the inferior vena cava. Resection and reconstruction of the renal vein using the gonadal vein

We succeeded in surgically resecting a leiomyosarcoma of the inferior vena cava (IVC), which originated at the confluent portion of the right renal vein (RRV), together with the IVC and RRV, and also were able to preserve the right kidney by reconstructing the RRV with end-to-end anastomosis using the right gonadal vein. A good blood flow of the reconstructed RRV was thereafter confirmed by color Doppler ultrasonography, and the renal function was also satisfactory. This new procedure, a reconstruction of the RRV using the gonadal vein, has not been previously reported, but is considered to be an easy and effective method which enables the surgeon to preserve the normal right kidney.

Leiomyosarcoma of the Right Atrium Masked by a Covering Thrombus: Conflicting Results of Echocardiography and Transvenous Biopsy-In Favor of Echocardiography

A 62-year-old woman was admitted for the evaluation of pedal edema and ascitis. Echocardiography revealed a right atrial (RA) mass invading the interatrial septum and extending into the inferior vena cava (IVC). Contrast enhanced computerized tomography scan excluded extravascular involvement. An organized thrombus was diagnosed by transvenous endomyocardial biopsy. The patient was treated with continuous intravenous heparin, and died soon after from hepatic failure. Postmortem histologic examination revealed a leiomyosarcoma surrounded by a thrombus involving RA, IVC, and hepatic veins. Endomyocardial biopsy played a misleading role that affected patient's management.