Intravenous leiomyomatosis complicated by Budd-Chiari syndrome

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.

Obstruction of the Hepatic Venous Flow Caused by Intravenous Leiomyomatosis

Budd–Chiari syndrome (BCS) is a rare intrahepatic vascular disease that is characterized by a hepatic venous outflow obstruction. Intravenous leiomyomatosis (ILs) is a rare complication of a myoma. Here, we report a case of BCS that was caused by intracaval ILs. A woman presented to the emergency department (ED) with abdominal distension that had gradually progressed over a period of 3 years. Bedside ultrasonography and contrast-enhanced computed tomography (CECT) showed a large ascites and pelvic mass. The mass continued to the inferior vena cava and the right atrium. The intracaval mass was obstructing the left and middle hepatic veins. We established a tentative diagnosis of BCS caused by intracaval ILs and attempted surgical resection. Complete resection of the intracaval mass failed because of adhesion; however, she was discharged from the hospital without any postoperative complications. After 3 months, a pelvic ultrasonography showed a recurrence of a 4 × 3 cm pelvic mass. The mass size increased to 6 cm after 30 months. ILs can cause secondary BCS and can lead to life-threatening conditions. Owing to its extreme rarity, early detection in the ED is challenging. Bedside ultrasonography and CECT can enable the early recognition of BCS by ILs.

Surgical treatment strategies for extra-pelvic intravenous leiomyomatosis

BACKGROUND

Extra-pelvic intravenous leiomyomatosis (IVL) extending into inferior vena cava (IVC) or heart (i.e. intracardiac leiomyomatosis, ICL) is an extremely rare benign disease. No consensus has been reached on the optimal surgical strategy. The aim of this study is to introduce four types of one-stage surgical strategies including less invasive options and a guideline to select patient-specific strategy for this disease.

METHODS

Twenty-four patients of extra-pelvic IVLs receiving one-stage resections at the Zhongshan Hospital from July 2011 to November 2019 were reviewed retrospectively. Base on the initial experiences of the indiscriminate choices of tumor thrombectomies through sterno-laparotomy under cardiopulmonary bypass (CPB) in 6 ICLs, an anatomy-based guideline for four types of surgical strategies was developed and applied for the next 18 patients.

RESULTS

Under the direction of guideline, tumor thrombectomies through single laparotomy were applied without CPB in 2 ICLs and 4 IVLs confined in IVC, or with CPB in 7 ICLs. Guideline-directed double-incisions with CPB were applied in only 5 ICLs, including 1 receiving mini-thoracotomy and 4 receiving sternotomy because of tumor adherences with right atriums in 2 and with pulmonary arteries in 2. All 24 patients accomplished one-stage panhysterectomy, bilateral adnexectomy and complete resections of intracaval and intracardiac tumors. For residual pelvic intravenous tumors in 19 patients, 17 received macroscopically complete resections while the other 2 failed because of high risk of hemorrhage. Intraoperative blood losses, operation time and hospitalization expense in the single-laparotomy non-CPB group were significantly lesser than the other groups. In CPB groups, inpatient stay and hospitalization expense in the single-incision group were significantly lesser than the double-incisions group. All patients were alive and free of recurrences during a mean follow-up of 35.4 ± 27.2 months (range, 1-100 months). The pelvic tumor residues in 2 patients remained unchanged for 51 and 52 months since operation, respectively.

CONCLUSIONS

For various extra-pelvic IVLs, the 4 types of surgical strategies including less invasive options are feasible, providing these are selected by a guideline base on the tumor extension and morphology. The proposed guideline is believed to accommodate more patients receiving less invasive surgery without compromising the curative effect.

Natural history of leiomyomas beyond the uterus

RATIONALE

Most leiomyomas are located in the uterus. Leiomyomas are rarely found outside the uterus and classified as leiomyoma beyond the uterus (LBU). This group consists of disseminated peritoneal leiomyomatosis, benign metastasizing leiomyoma, intravenous leiomyomatosis, parasite leiomyoma located in the broad ligament and retroperitoneal space. The descriptions of the patients who suffer from these types of leiomyomas are presented mainly in case reports.

PATIENT CONCERNS

A 34-year-old multiparous woman was operated on multiple recurrent uterine leiomyoma in parametrium. At one time, 32 leiomyomas were removed. Thirteen months following it, in next laparotomy, 132 leiomyomas were excised. Histologically, both were intravenous leiomyomas (IVLs).

DIAGNOSIS AND INTERVENTIONS

In follow-up, computed tomography (CT) and magnetic resonance imaging scans were performed to look for next recurrent leiomyoma. Accidentally, the mass was found in inferior vena cava which was diagnosed as intravenous vena cava leiomyoma. The mass was removed and the final diagnosis of intravenous myoma was confirmed in histopathology.

OUTCOMES

CT scan performed 3 months after the surgery for leiomyoma in vena cava revealed no pathology. Next 10 months' follow-up was uneventful.

LESSONS

The recurrent multiple uterine leiomyoma precede LBU. The uterine leiomyoma spreads intravenously route to parametria as parasite leiomyoma, then to vena cava. It has to be taken into account in follow-up.

Intracardiac leiomyomatosis: clinical findings and detailed echocardiographic features--a Chinese institutional experience

BACKGROUND

Intravenous leiomyomatosis is a rare, benign, smooth muscle tumor originating in the uterus that may extend through the inferior vena cava into the heart. Intracardiac leiomyomatosis (ICL), present in 10% of patients with intravenous leiomyomatosis, may cause right heart failure, tricuspid valve obstruction, and pulmonary embolism. The imaging characteristics of ICL continue to be reported. The purposes of this study were to characterize the echocardiographic features of ICL and to correlate the clinical findings.

METHODS

Between 1999 and 2012, 12 female patients with suspected ICL underwent cardiac surgery and histologic confirmation of the tumor. The clinical data, echocardiographic findings, and histologic results were retrospectively reviewed.

RESULTS

The ages of the patients with ICL ranged from 40 to 59 years. Ten patients (83%) had undergone myomectomy or hysterectomy, one patient had a uterine fibroid, and one patient had endometriosis. Seven patients (58%) reported dyspnea and/or palpitations, and one patient had syncope; four patients were asymptomatic. Echocardiographic findings included six patients with homogenous right atrial masses, four patients with myxoma-like right atrial masses, and two patients with serpentine, convoluted right atrial masses. In nine patients, the right atrial masses were noted to cross the tricuspid valve. All masses extended from the inferior vena cava. No masses appeared to adhere to the right atrium, right ventricular or pulmonary arterial walls, or tricuspid valve. Tricuspid regurgitation was noted in all patients. No pulmonary emboli were present.

CONCLUSIONS

The echocardiographic features of the ICL tumors varied. Tricuspid regurgitation and tumors emerging from the inferior vena cava were seen in all patients. Cardiac symptoms, including dyspnea, palpitations, and syncope, occurred in 67% of patients; the remaining 33% were asymptomatic.

Detection of intravenous leiomyomatosis with intracardiac extension by ultrasonography: A case report

Intravenous leiomyomatosis (IVL) is characterized by histologically benign tumors that exhibit aggressive clinical behavior. On rare occasions, the tumors may extend into the regional and systemic veins, thus reaching the heart. This may subsequently cause intracardiac leiomyomatosis (ICL), which may lead to congestive heart failure and occasionally, sudden fatalities. Due to its rarity and diffuse symptoms, the misdiagnosis of ICL is common and as a result, the condition may be under-reported. The present study reports a 33-year-old female who was admitted to Shandong Provincial Hospital Affiliated to Shandong University for myomectomy due to a rapidly growing myoma of the uterus. In routine pre-operative abdominal ultrasonography, a moderately sized echoic mass in the right internal iliac vein was observed, which extended to the common iliac vein, the inferior vena cava and the orifice of the right atrium. A presumptive diagnosis of ICL was made. The patient underwent a well-prepared one-stage thoraco-abdominal surgical procedure and the pathological report confirmed ICL. This case illustrates that the early detection of ICL may prevent a potential emergency situation and abdominal ultrasonography may be considered a useful tool in the diagnosis of ICL.

Intravenous leiomyomatosis with intracardiac extension - a review of diagnosis and management with an illustrative case

Intravenous leiomyomatosis with intracardiac extension is an uncommon pathologic progression of uterine leiomyomata. It is a histologically benign condition, however due to interfence with right sided cardiac function patients may present with marked cardiovascular compromise and present a diagnostic dilemma to clinicians who are unfamiliar with this condition. Given the rarity of this condition, experience in individual institutions is usually limited to a few cases. We present an illustrative case and provide a review of the clinical presentation, preoperative assessment, operative approach, pathology and postoperative issues. The importance of a multidisciplinary approach to diagnosis and management is highlighted. Operative management aims to completely resect all tumour in the safest manner for the patient, most commonly via single or two stage operation. Where complete resection is achieved, recurrence appears to be a rare event.

Intracardiac leiomyomatosis: a comprehensive analysis of 194 cases

Intracardiac leiomyomatosis is rare but has been increasingly reported in recent years. Owing to its rarity, intracardiac leiomyomatosis has been reported only as isolated case reports and case series. This disorder is thought to be underestimated and easily overlooked in the clinic, while it is dangerous owing to the risk of sudden death caused by total outflow tract obstruction. We performed an electronic literature search for intracardiac leiomyomatosis and identified 194 cases that were reported in English from 1974 (the first reported case) to September 2012. Our aim is to provide a detailed and comprehensive review of the clinical presentation, diagnosis, histopathological characterization, treatment and prognosis of this disorder. According to our analysis, intracardiac leiomyomatosis is most common in the fifth decade, and the mean age of detection is ~50 years. Most patients had undergone previous hysterectomy/myomectomy or had a coexisting uterine leiomyoma when admitted. The most common clinical presentations were dyspnoea, syncope, oedema of the lower extremities and palpitation. Transoesophageal echocardiography, computed tomography and magnetic resonance imaging are helpful in the preoperative diagnosis and to guide the surgical management. Complete removal guarantees an excellent outcome, with no recurrence or postoperative death, while incomplete removal leads to recurrence in one-third of patients. Anti-oestrogen therapy is not imperative after incomplete removal owing to its inability to prevent recurrence.

Infrarenal transcaval extraction of intracardiac leiomyomatosis

Intravascular leiomyomatosis is a rare, histologically benign disease, and can spread through the venous system to the right cavities of the heart. We report the case of a 39-year-old woman who presented with intravenous leiomyomatosis with extension to the right ventricle, causing heart failure. She underwent surgery successfully, undergoing a total resection of this tumor through the infrarenal cava and the hysterectomy in one surgical stage. Surgical technique considerations are discussed and the literature is reviewed.

Intravenous leiomyomatosis of the uterus with extension to the right heart

A 42-year-old woman admitted with debilitation and engorgement both lower extremities. Transthoracic two-dimensional echocardiography, abdominal ultrasound and computerized tomography revealed a lobulated pelvic mass, a mass within right internal iliac vein, both common iliac vein, as well as the inferior vena cava, extending into the right atrium. In addition, echocardiography and abdominal ultrasound showed the tumor of right atrium and inferior vena cave has no stalk and has well-demarcated borders with the wall of right atrium and inferior vena cave. Hence, the presumptive diagnosis of IVL was made by echocardiography and abdominal ultrasound and the presumptive diagnosis of sarcoma with invasion in right internal iliac vein, both common iliac vein, the inferior vena cava, as well as the right atrium was made by multi-detector-row computerized tomography. The patient underwent a one-stage combined multidisciplinary thoraco-abdominal operation under general anaesthetic. Subsequently the pathologic report confirmed IVL.

Partial resection of intravenous leiomyomatosis with cardiac extension

Intravenous leiomyomatosis with cardiac extension is rare and may result in a fatal outcome. A 58-year-old woman with a surgical history of myoma uteri was admitted to our hospital for treatment of intravenous leiomyomatosis extending into the right atrium through the inferior vena cava. We partially resected the tumor inside the right atrium and the inferior vena cava via the right atrium using cardiopulmonary bypass. There is no progression of the residual tumor after 25 months of follow-up.

Intravenous leiomyomatosis with intracardiac extension

Whereas uterine leiomyoma is a common woman disease, intravenous leiomyomatosis with intracaval and intracardiac complications is a rare condition. The initial presentation is dependent upon the severity of the intracardiac involvement, although complete surgery is the best treatment. The case of a 39-year-old woman is described here, with an initial presentation of dyspnea and right heart failure. Leiomyomatosis originating from the uterus and extending to the inferior vena cava and right atrium was diagnosed from various preoperative studies. The patient was resuscitated because of respiratory failure and severe right heart failure. However, she was operated successfully through a two-stage approach and remained well postoperatively. This case illustrates an intriguing presentation of intravenous leiomyomatosis and a curative surgical intervention even in critical condition.

An unusual case of recurrent mass in the right atrium: intravenous leiomyomatosis

Intravenous leiomyomatosis with a cardiac extension is an extremely rare condition. In this report, a case of a 43-year-old female patient is described: she was operated for right atrial mass protruding into the inferior vena cava, which was later diagnosed as leiomyoma. After a 3-year symptom-free period, recurrence of the extension through the inferior vena cava was observed. After abdominal ultrasonographic examination, which revealed bilateral ovarian and retroperitoneal mass, bilateral oopherectomy, retroperitoneal, and right atrial mass excision was done. The retroperitoneal and right atrial mass was reported as leiomyoma. On her last admission, she had complaints of dizziness, abdominal pain, and bilateral leg edema; and right atrial mass extending through the common iliac vein was noted, but the patient did not accept any further treatment modality.

Intravenous leiomyomatosis: two cases with different routes of tumor extension

Intravenous leiomyomatosis is a rare smooth muscle tumor. We report two cases of intravenous leiomyomatosis that grew along different routes of the venous system into the inferior vena cava and the right atrium. The different route of extension makes a difference in the ease of excision of tumor masses. Using MEDLINE together with the references in each publication, we identified all cases of intracardiac leiomyomatosis reported in the English literature in the period between 1980 and 2003 and performed a brief review on this potentially lethal disease entity.

Intracardiac leiomyomatosis: echocardiographic features

Intravenous leiomyomatosis is a histologically benign smooth-muscle tumor arising from either a uterine myoma or the walls of a uterine vessel with extension into veins. Echocardiographic features of two cases of intravenous leiomyomatosis with extensive spread into the right-sided cardiac chambers and pulmonary arteries are described. Both patients were middle-aged women, with prior history of hysterectomy 12 and 10 years earlier who presented with cardiac symptoms and signs. Distinctive echocardiographic features include 1) elongated mobile masses extending from the veins of the lower body, including inferior vena cava and azygos vein; 2) multiple venous attachments or metastases; and 3) filling of venous vessels and right-heart chambers. Intracardiac leiomyomatosis should be considered in a female patient presenting with an extensive mass in the right-sided cardiac chambers.