Primary smooth muscle tumors of the inferior vena cava

A contrast-enhanced CT-based radiomic nomogram for the differential diagnosis of intravenous leiomyomatosis and uterine leiomyoma

Objective

Uterine intravenous leiomyomatosis (IVL) is a rare and unique leiomyoma that is difficult to surgery due to its ability to extend into intra- and extra-uterine vasculature. And it is difficult to differentiate from uterine leiomyoma (LM) by conventional CT scanning, which results in a large number of missed diagnoses. This study aimed to evaluate the utility of a contrast-enhanced CT-based radiomic nomogram for preoperative differentiation of IVL and LM.

Methods

124 patients (37 IVL and 87 LM) were retrospectively enrolled in the study. Radiomic features were extracted from contrast-enhanced CT before surgery. Clinical, radiomic, and combined models were developed using LightGBM (Light Gradient Boosting Machine) algorithm to differentiate IVL and LM. The clinical and radiomic signatures were integrated into a nomogram. The diagnostic performance of the models was evaluated using the area under the curve (AUC) and decision curve analysis (DCA).

Results

Clinical factors, such as symptoms, menopausal status, age, and selected imaging features, were found to have significant correlations with the differential diagnosis of IVL and LM. A total of 108 radiomic features were extracted from contrast-enhanced CT images and selected for analysis. 29 radiomics features were selected to establish the Rad-score. A clinical model was developed to discriminate IVL and LM (AUC=0.826). Radiomic models were used to effectively differentiate IVL and LM (AUC=0.980). This radiological nomogram combined the Rad-score with independent clinical factors showed better differentiation efficiency than the clinical model (AUC=0.985, p=0.046).

Conclusion

This study provides evidence for the utility of a radiomic nomogram integrating clinical and radiomic signatures for differentiating IVL and LM with improved diagnostic accuracy. The nomogram may be useful in clinical decision-making and provide recommendations for clinical treatment.

Primary leiomyoma of the inferior vena cava mimicking a cystic neoplasm of the pancreas: a case report

Benign smooth muscle tumors of the inferior vena cava (IVC) are unusual, but mostly consist of intravenous leiomyomatosis, which arises from the uterus. Primary leiomyoma of the IVC is extremely rare. Here, we report a primary leiomyoma of the IVC, misleadingly reported as a cystic neoplasm of the pancreas in images. Immunohistochemical analysis was positive for (estrogen receptor) ER and (progesterone receptor) PR, indicating gynecologic leiomyomas. The use of ER and PR immunostaining is recommended to help distinguish between somatic and gynecologic leiomyomas, whose criteria of malignancy differ.

Asymptomatic Leiomyosarcoma of the Inferior Vena Cava

A case of leiomyosarcoma of the inferior vena cava is presented. The tumor was incidentally found at ultrasonography of a patient who underwent a follow-up examination after surgery for carcinoma of the colon. The tumor was resected and the patient was alive and well one year postoperatively at which time repeat ultrasonography and inferior vena cavography showed no remaining tumor.

Leiomyosarcoma of the Inferior Vena Cava

Inferior vena cava leiomyosarcoma is a rare tumor with a recent increase in incidence. The authors describe 2 cases and discuss clinical features, diagnosis, and treatment.

With recent advances in imaging methods and surgical procedures an early diagnosis and radical resection might be possible, leading to a better prognosis or even the cure of the disease.

Disseminated peritoneal leiomyomatosis: a rare cause of enigmatic peritoneal masses

Disseminated peritoneal leiomyomatosis (DPL) is an unusual extrauterine form of leiomyoma that has been found to coexist with its intrauterine counterpart in individuals who have previously undergone laparoscopic myomectomy. The presence of extrauterine masses with the density of smooth muscle on CT imaging and/or with a low signal intensity similar to that of smooth muscle on T₂ weighted MRI in a patient presenting with associated intrauterine leiomyoma and/or a history of previous laparoscopic myomectomy suggests the possibility of DPL. Imaging studies help in diagnosing and delineating the location and extent of the lesion and also follow-up the masses to look for sarcomatous transformation. Here we report the case of a 43-year-old female who presented initially with right lower quadrant pain. Her CT scan and MRI demonstrated a fundal fibroid with multiple intraperitoneal soft tissue masses of similar appearance and contrast enhancement in the sigmoid mesocolon, the left paracolic gutter and adjacent to the ascending colon. The suspected diagnosis of DPL was confirmed during abdominal hysterectomy, bilateral salphingo-oophorectomy and excision of peritoneal masses.

Intravenous leiomyomatosis with intracardiac extension: an unusual presentation of uterine leiomyoma and evaluation with 256-slice dual-source multidetector CT and cardiac MRI

We report a case of a 40-year-old woman who presented with breathlessness, palpitations and vague pelvic pain for 6 months. The dyspnoea was non-exertional and episodic. She was a non-diabetic, non-hypertensive and had no history of prior surgeries. ECG and chest radiograph were normal. Cardiac MRI and 256-slice dual-source multidetector CT evaluation revealed the presence of a uterine and left adnexal mass with intravenous extension into the inferior vena cava via the gonadal veins, and further cephalad extension into the right atrium and ventricle. The patient was referred to the cardiothoracic surgery department and underwent two-stage surgical procedures. The first stage consisted of thoracotomy and tumour removal from the right atrium and inferior vena cava. In the second stage, hysterectomy and bilateral salpingo-oophorectomy was performed. The histological analysis of the excised specimen was consistent with an intravascular leiomyoma.

Undifferentiated Intimal Sarcoma of the Inferior Vena Cava with Extension to the Right Atrium and Renal Vasculature

Primary sarcomas of the great vessels (aorta, pulmonary artery, and inferior vena cava (IVC)) are exceedingly rare. We report a rare case of an undifferentiated intimal sarcoma of the IVC with extension to the right atrium, adrenal, and renal veins. The patient underwent extensive resection, reconstruction of the IVC, and subsequent adjuvant chemotherapy. Patient has tolerated chemotherapy and, at 17 months after resection, the patient remains free of tumor recurrence. Undifferentiated intimal sarcomas remain a rare entity with only five cases of venous undifferentiated intimal sarcomas reported in the literature, two of which occurred in the IVC. Intimal sarcomas tend to carry a poor prognosis with the limited literature available on treatment approaches. Our objective is to highlight this rare entity and possible treatment approach which we utilized. Primary sarcomas of IVC need to be included as part of a complete differential diagnosis in patients with atrial masses or recurrent pulmonary emboli.

Renal vein leiomyoma: a rare entity with review of literature

Tumors of vascular origin are unusual. These tumors are predominantly malignant and commonly arise from the inferior vena cava. Benign smooth muscle tumors arising from renal vein are very rare. We present a case of leiomyoma of renal vein in a post-menopausal woman that clinically resembled a retroperitoneal paraganglioma.

Suprarenal symplastic leiomyoma of the inferior vena cava

We report on a case of a leiomyoma in the inferior vena cava that appeared in the image to be located in the adrenal gland. En bloc excision of the tumor with the right adrenal gland and the involved segment of the vena cava was carried out. Histopathological work-up of the tumor revealed smooth muscle fibers and marked nuclear pleomorphism consistent with symplastic leiomyoma. This case report presents a distinct histological variant of the rarely seen primary smooth muscle tumor of the inferior vena cava.

Vascular smooth muscle tumors: Review of the literature

Vascular smooth muscle tumors are very rare. They can be benign or malign. Intravascular leiomyomatosis is a benign neoplasm that extends through the veins and caries significant morbidity. Angioleiomyoma is a benign neoplasm of the extremities that caries minimal morbidity. Vascular leiomyosarcomas are malign neoplasms derived from vascular smooth cells. They are usually localized to the inferior vena cava, but can also arise from the pulmonary arteries or veins or other peripheral vessels. This study reviews literature for epidemiology, clinical presentation, diagnosis and management of patients with vascular smooth muscle tumors.

Intravenous leiomyomatosis

We present two cases of intravenous leiomyomatosis with uterine leiomyoma or previous hysterectomy because of uterine leiomyoma in which MRI was characteristic. MRI showed a mass in the inferior vena cava and the heart. These MR findings are useful in diagnosing intravenous leiomyomatosis.

Leiomyosarcoma of the inferior vena cava: a clinicopathologic review and report of three cases

BACKGROUND AND OBJECTIVES

We operated on three patients with leiomyosarcoma of the inferior vena cava.

METHODS

Complete excision was possible in all three patients.

RESULTS

One patient developed widespread metastasis at 23 months, one patient is alive with no evidence of disease at 70 months, and one patient is alive at 15 months. The third patient had subcutaneous and pulmonary metastases at the time of presentation, which are radiologically nondetectable at present following postoperative chemotherapy.

CONCLUSIONS

The clinicopathologic features, prognostic factors, and treatment of 130 cases found in a comprehensive literature search and our three cases are reported.

Intravenous leiomyomatosis

Intravenous leiomyomatosis is a rare tumor in which benign smooth muscle cells grow into the pelvic venous channels of female patients. A case of intravenous leiomyomatosis with cardiac extension in a 45-year-old woman is described. The patient was diagnosed with cardiac syncope 3 months after total abdominal hysterectomy and was successfully treated with a two-stage approach consisting of sternotomy followed by laparotomy. The cause, disease, presentation, diagnosis, treatment and recurrence are reviewed.

Intrahepatic leiomyosarcoma of the inferior vena cava with extension into the right atrium

We present a case of leiomyosarcoma of the intrahepatic inferior vena cava extending into the right atrium, that has been successfully palliated by removal of the obstructing tumour under conditions of full cardiopulmonary bypass and circulatory arrest. Lesions of this kind have previously thought not to be amenable to surgery. Although resection was incomplete, successful palliation may be achieved facilitating this technique.

[Leiomyosarcoma of the vena cava. Case report and review of the literature]

The leiomyosarcoma of vascular origin is a very rare tumor which is rarely recovered before the disease has reached an advanced stage because of non-specific and late symptoms. This is a report of 3 cases with leiomyosarcoma of the vena cava and a review of the literature. A high local recurrence rate and high frequency of distant metastases are responsible for the bad long-term prognosis. Early hematogenous tumor spread is favored by intraluminal tumor growth. Only complete surgical resection--if necessary with vascular reconstruction--can improve the bad long-term prognosis.

Acute Budd-Chiari syndrome secondary to leiomyosarcoma of the inferior vena cava

The authors report a case of leiomyosarcoma of the inferior vena cava, responsible for an acute Budd-Chiari syndrome. The diagnosis, suggested by lower limb edema, ascites, and renal failure, was confirmed by sonography, CT scan, and pathological examination. A mesoatrial shunt and right atrial thrombectomy were performed under extracorporeal circulation. The inferior vena cava was ligated because the tumor was considered to be unresectable.

Primary leiomyosarcoma of the inferior vena cava with Budd-Chiari syndrome

A 44-year-old Japanese woman with leiomyosarcoma of the inferior vena cava is reported. She presented with Budd-Chiari syndrome and died of hepatic failure about 3 months after the onset of symptoms. The tumor arose from the middle segment of the inferior vena cava, occluded the inferior vena cava and projected into the right atrium. A total of 28 cases of Budd-Chiari syndrome due to primary leiomyosarcoma of the inferior vena cava are reviewed.

Leiomyosarcoma of the renal vein: a case report

We report a rare case of leiomyosarcoma of the renal vein. There have been only 5 other such cases reported in the literature. Special attention is focused on the diagnostic problems and the paucity of presenting symptoms. The literature is reviewed briefly.

Intra-vascular leiomyoma of the popliteal vein

A large mass in the popliteal fossa was found to be a leiomyoma of the popliteal vein with portions of tumour both inside and outside the vein. This is only the second recorded case of a benign smooth muscle tumour of a peripheral vein.

Leiomyosarcoma of inferior vena cava

A case of leiomyosarcoma of the inferior vena cava is presented and pertinent clinical features of 57 reported cases in the English literature are reviewed.

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

Sixty-six cases of leiomyosarcoma of the inferior vena cava (IVC) have been reported. We present another case and review the characteristics and treatment of this rare tumor. IVC leiomyosarcomas spread by extension into adjacent tissue planes. Direct extension into the heart is known, but not into the kidneys, adrenals, or bowel. IVC leiomyosarcomas arising below the renal vein cause pain in the right-lower quadrant, back, and flank, and varying degrees of lower extremity edema; those arising in the middle caval segment cause right-upper-quadrant pain and sometimes renovascular hypertension; those arising above the hepatic vein cause varying manifestations of the Budd-Chiari syndrome. A reasonable approach to early diagnosis involves oral and intravenous contrast studies followed by computed tomography, angiography, and vena cavography. Aggressive surgical treatment is optimal in light of the tumor's slow growth pattern and relatively low malignant potential. (Metastases have been reported in fewer than 50% of cases). Tumors involving the lower IVC are most amenable to surgery; extensive collateral venous drainage of the left kidney preserves renal function during resection of middle caval tumors. Upper caval leiomyosarcomas are the least amenable to complete removal. Postoperative survival of all patients has ranged from a few weeks to eight years.

Leiomyosarcoma of the inferior vena cava presenting as a suprarenal mass

Leiomyosarcoma of the inferior vena cava is a rare disease with protean manifestations related to the location of the tumor. Urological manifestations of the disease are rare and include renal vein thrombosis and renovascular hypertension. Approximately 63 cases have been reported in the literature, with a striking female predominance. Presentation as an isolated suprarenal mass has not been reported previously. We discuss this unusual tumor and report a case that presented as an asymptomatic suprarenal mass.

Leiomyosarcoma of the inferior vena cava

A case of leiomyosarcoma of the inferior vena cava of a 46-year-old man is presented, and review of 51 cases of this type of malignant tumor is made. The biological behavior of this tumor and various treatment modalities are discussed.

Primary smooth muscle tumors of venous origin

Vein tumors are rare, difficult to diagnose, and usually malignant. We have encountered three: a leiomyoma of the jugular vein and leiomyosarcomas of the saphenous vein and inferior vena cava (IVC). The leiomyoma was lost to follow-up, the saphenous vein leiomyosarcoma survived nine years, and the leiomyosarcoma of the IVC is six months without recurrence. Half of venous leiomyosarcomas arise in the IVC, predominately in women over 50 years of age. Surgical excision is the treatment of choice since malignant or benign status cannot be determined operatively. Resection should include a segment of the original vessel. This poses problems in the IVC when the renal veins require sacrifice. Right renal vein interruption mandates nephrectomy. Edema following IVC resection is evaluated. The incidence is lower than anticipated when resection is for tumor if there is no history of phlebitis. The IVC was reconstructed with a composite autograft but this is not now recommended. Despite significant local recurrences or distal metastases, cure or long-term palliation can often be achieved. Radiation and chemotherapy do not improve survival or prevent recurrence.

Leiomyosarcoma of the inferior vena cava. A case report with a review of the literature

A patient with leiomyosarcoma of the inferior vena cava is reported and a total of 65 cases is reviewed.

Tricuspid stenosis due to intravenous leiomyomatosis--a call for caution: case report and review of the literature

Extension of a benign intravenous leiomyomatous tumor from the pelvis into the right atrium resulted in severe tricuspid stenosis in a 28-year-old woman. Absence of the Budd-Chiari syndrome and other abdominal manifestations led to a misdiagnosis of a primary right atrial tumor, with a fatal outcome during operation. In our search of the English literature, this was only the second case found in which extensive intravenous leiomyomatosis interfered with the tricuspid valve mechanism. In this report, the clinical picture, etiology, and treatment are discussed, along with the literature on this rare entity.

Leiomyosarcoma of the inferior vena cava: angiographic and computed tomography findings. Report of two cases and review of imaging criteria

Leiomyosarcoma, a highly malignant tumor of the inferior vena cava, is rare. Only 55 cases have been reported in the world literature, and of these only 18 were evaluated with a special vascular procedure, either arteriography or inferior vena cavography. In two cases of leiomyosarcoma of the inferior vena cava, we performed arteriography and inferior vena cavography. In one, computed tomographic studies were also carried out. Cavography showed a lobulated filling defect in one case and complete caval occlusion with collateral circulation in the other. In the one case in which it was performed, computed tomography clearly demonstrated the tumor's size and its relationship to surrounding organs. Arteriographic studies, however, allowed only an indistinct delineation of the extent of tumor growth in one case. Venography followed by computed tomography should permit adequate assessment of most leiomyosarcomas of the inferior vena cava, with arteriography reserved for tumors involving the upper cava in which hepatic involvement must be evaluated.

Angiography in leiomyosarcoma of the inferior vena cava--report of two cases

Two patients with leiomyosarcoma of the suprarenal inferior vena cava are presented. In one case the tumour was misinterpreted as intrahepatic at angiography. In the second case an extrahepatic location was suggested after repeated angiography. The diagnosis should be borne in mind when a large hypovascular mass appears to be located centrally in the liver at coeliac angiography and when ultrasound examination has revealed its solid nature.

Leiomyosarcoma of artery and vein

Five cases of leiomyosarcoma of blood vessels--three venous, two arterial--are reported. Treatment was surgical alone in two patients with involvement of the internal mammary artery and the long saphenous vein. The other three were treated initially by surgery, followed by radiation therapy, and surgery aimed at either total or partial removal of metastases. Two patients are alive and well, free of disease. Two patients have died of their disease despite all modalities of treatment, and one patient has a life-threatening metastases and is not expected to survive.

Leiomyosarcoma of the inferior vena cava

The thirty-second case of leiomyosarcoma of the inferior vena cava and the twelfth resectable patient in the series is presented. A review of the literature demonstrates a marked female preponderance (5 to 1). The most common presenting symptom is right abdominal pain and a palpable mass. The different surgical problems generated by the involved segment of the cava are discussed. Noteworthy is the high incidence of Budd-Chiari syndrome owing to hepatic vein obstruction with involvement of the upper third of the cava in the postmortem cases. An argument is developed for debulking the tumor for palliation when it is not completely removable.

Leiomyosarcoma of the inferior vena cava: report of a case and review of the literature

Leiomyosarcoma of the inferior vena cava is a rare and usually fatal disease. Only 45 cases have been reported in the world literature. The authors add one case and review all previous reports. The disease is one primarily of elderly women, arising from the middle third of the inferior vena cava with a wide range of symptomatology, varying form the Budd-Chiari syndrome to a few asymptomatic cases. The tumor may grow very slowly or occasionally very rapidly, shows extensive local invasion, and metastasizes more frequently than previously believed. While radiotherapy and chemotherapy have not been adequately studied, aggresive surgical intervention using the recent advances in vascular surgery appears to offer long term palliation and hopefully cures of this disease in the future.

Mesenchymal tumors of the uterus. V. Intravenous leiomyomatosis. A clinical and pathologic study of 14 cases

Fourteen examples of intravenous leiomyomatosis in the FIP files were studied. Growth beyond the uterus occurred in 10 of the 14 examples, largely in vessels in the broad ligament and in uterine and iliac veins. Metastasis to the heart occurred in 1 example. The study provides evidence that is consistent with both theories of origin of intravenous leiomyomatosis; namely, that it may arise either from the wall of veins within the myometrium or be a result of unusually extensive vascular invasion from a leiomyoma of the myometrium. Intravenous leiomyomatosis should be distinguished from a leiomyoma with vascular invasion by arbitrarily limiting the designation of leiomyoma with vascular invasion to neoplasms in which the vascular growth is a microscopic finding and confined within the leiomyoma. Criteria are given for distinguishing intravenous leiomyomatosis from endometrial stromal sarcoma, leiomyosarcoma, leiomyoma with vascular invasion, and leiomyomatosis peritonealis disseminata.

Unusual intracardiac tumor in a child. Inflammatory pseudotumor or "granulomatous" variant of myxoma?

An intracardiac tumor arising in the right atrium of a young child is reported. Morphologically, the lesion was reminiscent of "plasma cell granulomas," but unprecedented in this location. Based on clinical manifestations, laboratory findings, histologic and ultrastructural characteristics of the mass, the speculation is put forth that this lesion may represent a cardiac myxoma with atypical structural features. An extension of this proposal is a pathogenetic sequence that would try to reconcile the complex clinical course of some myxomas with the described structural observations. Alternative choices for classification of the lesion are also given consideration.