Clinical analysis of uterine intravenous leiomyomatosis: A retrospective study of 260 cases

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.

Ultrasound diagnostic value and clinical analysis of 61 uterine intravenous leiomyomatosis cases

Background

Intravenous leiomyomatosis (IVL) is a rare benign smooth muscle tumor, for which the ultrasound features and diagnostic value have rarely been reported due to its infrequent presentation. This study aimed to analyze ultrasonographic characteristics and diagnostic value of uterine IVL and explore risk factors influencing postoperative recurrence.

Methods

A retrospective analysis was conducted of 61 patients who underwent surgical treatment from December 2014 to December 2023. Intraoperative or postoperative pathology confirmed uterine IVL in these patients. Clinical data and ultrasonographic features were analyzed, including IVL location, the International Federation of Gynecology and Obstetrics (FIGO) classification, shape, involved vessels, extent of involvement, internal blood flow, and ultrasound diagnostic accuracy. Cumulative recurrence rates were calculated using Kaplan-Meier method, and the survival curves for clinical factors were analyzed. Prognostic analysis of IVL recurrence was performed using Cox proportional hazard model.

Results

The diagnostic accuracy of ultrasound for IVL was 55.7% (34/61). The diagnostic accuracy of ultrasound was 76.7% for para-uterine IVL (P<0.001), 76.9% for FIGO 8 category (P<0.001), 84.4% for cord-like or beaded morphology (P<0.001), 92.3% for the involvement of the iliac vessels or inferior vena cava (IVC, P=0.003), and 66.7% for abundant internal blood flow (P=0.213). During the follow-up period, IVL in 10 cases (16.4%) recurred. The cumulative recurrence rates were 10.5%, 12.8%, and 18% at 1, 2, and 3 years, respectively. Patients aged ≤46.5 years (P=0.010), with IVL involving the iliac vein or IVC (P=0.017), and undergoing myomectomy (P<0.001) had a higher recurrence rate. Univariate analysis identified age (≤46.5 years) (P=0.035), IVL involving the iliac veins or IVC (P=0.029), and myomectomy (P<0.001) as risk factors for recurrence. Multivariate analysis showed that IVL involving the iliac veins or IVC [P=0.021, hazard ratio (HR) 6.407] and myomectomy (P<0.001, HR 77.360) were independent risk factors for recurrence.

Conclusions

The diagnostic accuracy of ultrasound was high for IVL located adjacent to the uterus and in FIGO 8 category, especially when it presented with cord-like or beaded morphology and involved the iliac vessels or IVC. Involvement of the iliac veins or IVC and myomectomy were independent risk factors for IVL recurrence. The risk of recurrence for IVL involving the iliac veins or IVC was 6 times higher than that confined to the uterus or para-uterine veins, and the risk of recurrence was 77 times higher for myomectomy than for hysterectomy with bilateral oophorectomy.

Intravenous leiomyomatosis presenting as Budd-Chiari syndrome: a case report and literature review

BACKGROUND

Budd-Chiari syndrome (BCS) caused by intravenous leiomyomatosis (IVL) is rare. Further reports and thorough evaluation are needed to identify and manage this disease.

METHOD

We described the case of a 49-year-old lady, exhibiting features of BCS secondary to IVL, and reviewed three other previous cases of BCS caused by IVL.

RESULTS

The mean onset age of these four patients was 54.8 years. All but one (Patient No. 2) had a history of myoma, myomectomy, or hysterectomy. Abdominal pain, bloating or increasing abdominal circumference, and bilateral lower extremity edema were common symptoms. The establishment of clinical diagnoses of IVL and BCS mainly depends on clinical presentations and imaging, such as ultrasonography, computed tomography, and magnetic resonance imaging. Surgical intervention to alleviate the hepatic veins outflow obstruction is the most important treatment.

CONCLUSIONS

BCS caused by IVL should be considered when the inferior vena cava and right atrium lesions were detected in a patient with characteristics of BCS and a history of uterine myoma or hysterectomy. Complete tumor resection is the only curative treatment and should be performed as soon as possible.

Ultrasound findings of ovarian intravenous leiomyomatosis: a case report

Intravenous leiomyomatosis (IVL), an abnormal growth pattern of uterine leiomyomas, is a rare tumor characterized by masses of smooth muscle cells appearing histologically benign and proliferating within the blood vessels but not invading the tissue. Currently, there have been limited reports of early cases of IVL, and the imaging characteristics of IVL remain uncertain, resulting in frequent misdiagnosis prior to surgery. The present study utilized a case of early IVL detected through conventional ultrasound and subsequently confirmed via contrast-enhanced ultrasound (CEUS) to further investigate ultrasound's diagnostic efficacy for early IVL detection. Here, a case of a 49-year-old woman was reported who presented with uterine leiomyoma and an echogenic mass in the left adnexal region on physical examination. Subsequent transvaginal CEUS examination revealed a left ovarian venous leiomyoma. The patient underwent resection of tumors in the uterus, bilateral ovaries, and left ovarian vein under general anesthesia. A venous plexus was identified above the left broad ligament close to the left ovary, and a myoma-like growth was detected in the posterior uterine wall during the operational procedure. Reports on pathology and immunohistochemistry verified leiomyomatosis with fatty metaplasia in the left broad ligament and uterine wall vein. The prognosis of patients with IVL is determined based on the appropriate surgical methods and the timely diagnosis of the condition. In this case, conventional ultrasound aided in the early identification of IVL, which was later verified by a CEUS examination, resulting in a successful surgical treatment. This example highlights the importance of ultrasound technology in diagnosing this uncommon condition and presents a new method for preoperative detection of IVL.

Ultrasound Appearance of Intravascular Uterine Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Case Report

A 43-year-old patient with a history of uterine fibromatosis was referred to our hospital for menometrorrhagia and pelvic pain. At the pelvic ultrasound, a highly-vascularized myometrial lesion in volumetric increase was described. An elongated, solid, hypoechoic, painless, and highly vascularized left parauterine mass was identified. On histological examination, a uterine smooth muscle tumor of uncertain malignant potential (STUMP) with intravascular invasion of the left uterine vein was diagnosed. The adnexa and peritoneum were free of disease. On a retrospective evaluation of the ultrasound images, we noticed that the intravascular lesion showed sonographic features comparable to the original mass. Moreover, the Color Doppler (CD) analysis revealed an interrupted blood flow within the left uterine vein. In this case, the ultrasound proved to be an accurate diagnostic tool. When inhomogeneous uterine masses are suspected, and a parauterine/paraadnexal mass surrounded by irregular vessels are identified, the sonographer should take into account a risk of intravascular invasion. The patency of uterine and ovarian vessels should be accurately evaluated, to guide a tailored patient surgical approach.

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.

Intravascular Leiomyoma Considered Preoperatively as Uterine Sarcoma: A Rare Case

Intravascular leiomyoma (IVL) is usually defined as a histologically benign leiomyoma that originates in a uterine fibroid or the intrauterine vein wall and grows and expands intravenously. We report a case in which pelvic IVL was detected early and discuss the early diagnosis of and best treatment for this tumor.

MR imaging findings of stage I intravenous leiomyomatosis: a retrospective single-center study in 19 cases

OBJECTIVES

The aim was to explore the magnetic resonance imaging (MRI) features of stage-I intravenous leiomyomatosis (IVL).

MATERIALS AND METHODS

From January 2019 to January 2023, clinical, pathological, and MRI data were collected from 19 cases confirmed by surgical pathology. Two radiologists retrospectively measured the tumor sizes, T1WIs, T2WIs, and ADC values and evaluated contrast-enhanced T1WIs, DWIs, complications and parauterine infiltrations. The number of tumor cells and the total nuclear area were measured. The percentage of tumor cell area out of the total area was used as the tumor cell density.

RESULTS

Nineteen patients with stage-I IVL aged 33 to 66 years (mean age: 46 ± 7.6 years) were included in this study. All 19 cases were located in the myometrium or parametrium, with a mean diameter of 11.2 ± 4.8 cm. Among these cases, 14 (73.6%) were associated with leiomyoma, and six (31.6%) involved the broad ligament. Isointensity was observed in the T1WIs of 12 cases (63.2%), while slight hypointensity was seen in five patients (26.3%). Isointensity was observed in the on T2WIs of four cases (21.1%), and iso- or slight hyperintensity was observed in 15 cases (78.9%). A significant difference was detected between the normalized T2WIs of IVL and myometrium (p < 0.001). A Pearson correlation test showed demonstrated a negative correlation between the ADC and tumor cell density values (r = - 0.946, p < 0.001). Tortuous vessels were present in 17 cases (89.5%) within or next to the lesions, and multiple winding cord-like filling defects were seen in 11 cases (57.9%) within the tortuous vessels on the T2WIs.

CONCLUSION

Identifying the characteristic MRI features of stage-I IVL helped improve the diagnostic accuracy achieves for this rare tumor. Stage-I IVL often presents as a large mass accompanied by leiomyoma, and it easily invades the broad ligament. TIWI signals exhibited isointensity, and T2WI signals contained iso- or slight hyperintensity. Tortuous vessels were present within or next to the lesions, and multiple winding cord-like filling defects were observed within the tortuous vessels on the T2WIs.

Different clinical diagnosis end up in the same pathological diagnosis of intravascular leiomyomatosis: Two case reports

RATIONALE

Intravascular/intravenous leiomyomatosis (IVL) is a peculiar variant of uterine leiomyoma that is classified as a histologically benign smooth muscle tumor with a biological behavior similar to that of a malignant tumor. It is characterized by the proliferation of leiomyomas spreading along the uterine and extrauterine venous circulation.

PATIENT CONCERNS

Herein, we present 2 cases of IVL who had completely different clinical manifestations to stress the need for constant vigilance of IVL diagnosis and the understanding of uterine leiomyoma heterogenicity. Case 1 was registered for fever without specific triggering factors, irregular menstruation and clinically diagnosed uterine diverticula, while no information about fibroids was mentioned. Case 2 was characterized by an aggressively growing abdominal mass. With a large space-occupying lesion in the right abdominopelvic cavity and no imaging evidence of involvement of the iliac vein or above vein, the patient was initially diagnosed with multiple myomata.

DIAGNOSES

Both patients' diagnoses were confirmed as IVL by histopathology. To our knowledge, the mass of case 1 is the minimum IVL in the English literature.

INTERVENTIONS

Subtotal hysterectomy with bilateral salpingectomy was performed on the former, while total hysterectomy with bilateral salpingectomy was performed on the latter.

OUTCOMES

Both patients were comfortable, and no relapse occurred.

LESSONS

Two cases in the study showed 2 different proceeding stages of the same disease and corroborated multiple pathogeneses, which have been mentioned in the available literature on IVL. Our work provides both supplement for clinical data to facilitate further research and better understanding of special types of fibroids to clinicians.

Update on clinical characteristics and molecular insights for uterine intravenous leiomyomatosis (Review)

Intravenous leiomyomatosis (IVL) is a rare benign disease, which typically develops along vascular vessels and extends to the inferior vena cava and right atrium of the heart. In the early stages of the disease, the clinical manifestations and the results of imaging examinations are not uniform among patients. Thus, a high rate of misdiagnosis and missed diagnosis is common. When the tumor extends along the venous system to the pelvic floor vein or through the inferior vena cava involving the right atrium of the heart or the pulmonary artery, severe symptoms occur, such as ascites, dyspnea, heart failure and even sudden mortality. Improving the understanding of IVL to identify and evaluate this disease in its early stages is important. Complete tumor resection remains the primary treatment option for IVL. The recurrence rate of the disease varies depending on multiple factors, such as type of surgical procedure performed. Therefore, long-term follow-up is necessary for patients with IVL. The review of recent findings on the molecular and clinicopathological characterization of IVL is important to understand the pathogenesis of IVL. In the present study, the clinical manifestations, pathogenesis, differential diagnosis, treatment and prognosis of IVL are summarized in order to provide a single source of insightful information on IVL.

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.

68 Ga-FAPI and 18 F-FDG PET/CT in Intravenous Leiomyomatosis

ABSTRACT

Intravenous (IV) leiomyomatosis is a rare IV disease. Our case presents 68 Ga-FAPI and 18 F-FDG PET/CT findings of IV leiomyomatosis in a 37-year-old woman. Intravenous leiomyomatosis shows only mild FDG but intense 68 Ga-FAPI activity on PET/CT studies. In this case, 68 Ga-FAPI was superior to 18 F-FDG PET/CT in detecting IV leiomyomatosis.

Clinical features and prognostic factors analysis of intravenous leiomyomatosis

Background

The treatment and prognostic factors of intravenous leiomyomatosis (IVL) remain lacking systematic evidence.

Methods

A retrospective study was conducted on IVL patients from the Qilu Hospital of Shandong University, and IVL cases were published in PubMed, MEDLINE, Embase and Cochrane Library databases. Descriptive statistics were used for the basic characteristics of patients. The Cox proportional hazards regression analysis was used to assess the high-risk factors related to the progression-free survival (PFS). The comparison of survival curves was performed by Kaplan-Meier analysis.

Results

A total of 361 IVL patients were included in this study, 38 patients from Qilu Hospital of Shandong University, and 323 patients from the published literature. Age ≤45 years was observed in 173 (47.9%) patients. According to the clinical staging criteria, stage I/II was observed in 125 (34.6%) patients, and stage III/IV was observed in 221 (61.2%) patients. Dyspnea, orthopnea, and cough were observed in 108 (29.9%) patients. Completed tumor resection was observed in 216 (59.8%) patients, and uncompleted tumor resection was observed in 58 (16.1%) patients. Median follow-up period was 12 months (range 0-194 months), and 68 (18.8%) recurrences or deaths were identified. The adjusted multivariable Cox proportional hazard analysis showed age ≤45 years (vs. >45) (hazard ratio [HR] = 2.09, 95% confidence interval [CI] 1.15-3.80, p = 0.016), and uncompleted tumor resection (vs. completed tumor resection) (HR = 22.03, 95% CI 8.31-58.36, p < 0.001) were high-risk factors related to the PFS.

Conclusion

Patients with IVL have a high probability of recurrence after surgery and a poor prognosis. Patients younger than 45 years and with uncompleted tumor resection are at higher risk of postoperative recurrence or death.