Leiomyosarcoma of the Inferior Vena Cava: Surgical Management and Clinical Results

Inferior vena cava tumor thrombus: clinical outcomes at a canadian tertiary center

OBJECTIVE

This study reports the surgical management and outcomes of patients with malignancies affecting the IVC.

METHODS

This was a retrospective study that considered patients undergoing surgery for IVC thrombectomy in Calgary, Canada, from 1 January 2010 to 31 December 2021. Parameters of interest included primary malignancy, the extent of IVC involvement, surgical strategy, and medium-term outcomes.

RESULTS

Six patients underwent surgical intervention for malignancies that affected the IVC. One patient had a retroperitoneal leiomyosarcoma, 1 had hepatocellular carcinoma with thrombus extending into the IVC and right atrium, 1 had adrenocortical carcinoma with IVC thrombus extending into the right atrium, and 3 had clear cell renal cell carcinoma with thrombus extending into the IVC. Surgical strategy for the IVC thrombectomy varied where 5 patients required the institution of cardiopulmonary bypass and underwent deep hypothermic circulatory arrest. No patient died perioperatively. One patient died 15-months post-operatively from aggressive malignancy.

CONCLUSION

Different types of malignancy can affect the IVC and surgical intervention is usually indicated for these patients. Herein, we have reported the outcomes of IVC thrombectomy at our center.

Approach to Different Types of Inferior Vena Cava Leiomyosarcomas: A Vascular Surgeon's Perspective

Leiomyosarcoma (LMS) is a rare smooth muscle tumor, and only a few cases have been reported with involvement of the inferior vena cava (IVC). Inferior vena cava LMS is more often silent and usually has a poor prognosis as the patients present late. We present this case series to showcase the different approaches to surgical resection, as each tumor had a different location in the IVC. We emphasize preoperative surgical planning to achieve a tumor-free margin and maintain hemodynamics at the same time.

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

BACKGROUND

Leiomyosarcoma is classified as a soft tissue sarcoma. In adults, leiomyosarcoma is the most common malignancy affecting the vascular system; however, vascular leiomyosarcoma in children is extremely rare as most pediatric soft tissue tumors are rhabdomyosarcomas. The survival rate is very low, and incomplete resection is a poor prognostic factor. There is also a high rate of distant recurrence, with the lungs and liver being the most common sites of metastasis. There is no established effective chemotherapy, and complete surgical resection is the only potentially curative treatment for leiomyosarcoma.

CASE PRESENTATION

A 15-year-old female patient with no significant medical history presented with severe upper abdominal pain and was admitted. Abdominal contrast-enhanced computed tomography and magnetic resonance imaging showed a large retroperitoneal tumor protruding into the lumen of the inferior vena cava behind the liver and multiple small nodules, and metastasis to the liver was suspected. The tumor was 6 × 4 × 5 cm in diameter, located just behind the hepatic hilar structures, and was suspected to infiltrate into the right portal vein. The tumor was diagnosed as a leiomyosarcoma through an open tumor biopsy. As the multiple liver metastases were located only in the right lobe of the liver on imaging, we performed tumor resection with right hepatectomy and replacement of the inferior vena cava (IVC). The postoperative course was uneventful; however, on postoperative day 51, distant metastatic recurrences were found in the remaining liver and right lung. The patient was immediately started on chemotherapy and trabectedin proved to be the most effective drug in the treatment regimen; however, severe side effects, such as hepatotoxicity, prevented timely administration, and the patient passed away 19 months after surgery.

CONCLUSIONS

IVC resection and reconstruction combined with right hepatectomy were able to be safely performed even in a pediatric case. To improve the prognosis of leiomyosarcoma with multiple metastases, an effective treatment strategy combining surgical treatment and chemotherapy, including molecularly targeted drugs, should be established as early as possible.

Treatment outlines for the management of primary leiomyosarcoma of the inferior vena cava

Primary venous Leiomyosarcoma (LMSs) are extremely rare tumours with poor survival rates. Surgery is currently the only potentially curative therapy in non-metastatic disease, but it consists in challenging interventions. The authors report the experience of one single centre in the treatment of LMS and a literature overview focusing on the diverse methods of vessels repair. Outcomes achieved are also outlined.

Current update on IVC leiomyosarcoma

Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare soft tissue sarcoma associated with poor prognosis. Patients are often asymptomatic or present with nonspecific abdominal symptoms, which delays initial diagnosis and contributes to poor oncologic outcome. Key imaging modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Characteristic imaging features include imperceptible caval lumen, dilation of the IVC, heterogeneous enhancement of the tumor, and development of extensive collateral circulation. Surgical resection is the mainstay of treatment, while chemotherapy and/or radiation may serve as therapy adjuncts. This article reviews the pathology, clinical findings, imaging features and management of IVC leiomyosarcoma.

Primary leiomyosarcoma of the inferior vena cava: Is vascular reconstruction always necessary?

Both MRI and CT scan can determine tumor size and its extension. PLV have a poor prognosis if surgical resection cannot be achieved. We recommend no reconstruction for type II PLV if venous contact is less than 180° or where the implantation base does not exceed one third of the vena cava.

Surgical and reconstructive outcomes in primary venous leiomyosarcoma

OBJECTIVES

Primary venous leimyosarcomas (PVL) are rare and pose challenges in surgical management. This study evaluates the clinical outcomes and identifies predictors of survival in our surgical series of PVL.

METHODS

A retrospective review was performed of patients who had resection of PVL at three centers between 1990-2018. Patient demographics, comorbidities, intraoperative data, survival, and graft related outcomes were recorded. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression.

RESULTS

Seventy patients with a diagnosis of PVL were identified between 1990 and 2018. Fifty-four patients (77%) had PVL of the IVC and 16 (23%) had peripheral PVL. Mean follow up for the series was 55.0 months (range 1-217 months). Fifty one patients (96%) with IVC PVL needed caval reconstruction and 3 (4%) had resection only. There were no deaths within thirty days of surgery. Five patients (9%) required early re-intervention including one (2%) IVC stent. Sixteen peripheral PVL were identified. Eight patients (50%) had venous reconstructions performed and 8 (50%) had the vein resected without reconstruction. There were no deaths within thirty days. Five year survival was 57.5% for IVC PVL and 70.0% for peripheral PVL . Kaplan-Meier survival analysis for IVC and peripheral PVL revealed no difference in overall survival (p = 0.624) at 5 years.

CONCLUSIONS

PVL is a rare and aggressive disease even with surgical resection. We found no difference in survival between IVC and peripheral lesions suggesting aggressive management is warranted for PVL of any origin. Management of PVL requires a multidisciplinary approach to provide patients with the best long term outcomes.

Surgical Resection of Tumors Invading the Inferior Vena Cava at the Hepatic Vein and Thoracic Levels

BACKGROUND

Our aim was to describe the results of our program of surgical resection of tumors invading the inferior vena cava (IVC) at the hepatic and thoracic levels. We hypothesized that similar surgical outcomes may be obtained compared to tumor resection below the hepatic vein level if the liver function was preserved.

METHODS

We performed a single-center retrospective study of 72 consecutive patients who underwent surgical resection from 1996 to 2019 for tumors invading the IVC. We compared two groups based on tumor location below (group I/II) or above (group III/IV) the inferior limit of hepatic veins.

RESULTS

Tumor histology was similarly distributed between groups. In group III/IV (n = 35), sterno-laparotomy was used in 83% of patients, cardiopulmonary bypass in 77%, and deep hypothermic circulatory arrest in 17%; 23% underwent liver resection. Corresponding proportions in group I/II were 3%, 0%, 0%, and 8%. In group III/IV, 4 patients required emergency resection. Mortality on day 30 was 17% (n = 6) in group III/IV and 0% in group I/II (P = 0.01). There was no liver failure among the 66 postoperative survivors and 5 out of 6 patients who died postoperatively presented a preoperative or postoperative liver failure (P < 0.001). Overall survival was not significantly different between groups with a median follow-up of 15.1 months. R0 resection was achieved in 66% of group I/II and 49% of group III/IV patients (P = 0.03).

CONCLUSION

Surgical resection of tumors invading the inferior vena cava at hepatic vein and thoracic levels should be reserved to carefully selected patients without preoperative liver failure to minimize postoperative mortality.

Giant leiomyosarcoma of the inferior vena cava necessitating extended liver resection: A case report and review of the literature

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumour of smooth muscle origin. It commonly presents with non-specific symptoms including abdominal pain, distention, and lower extremity edema. Surgical resection with macroscopically clear margins is the only potential curative treatment for the disease. Here we present the case of a previously healthy 38-year-old woman with a subacute one-month increase of a four-year slowly progressive right sided abdominal pain and back pain. Imaging revealed a 14.5x12x15cm mass in the right hepatic lobe causing mass effect on adjacent abdominal and retroperitoneal organs, and involving the retrohepatic IVC. En-bloc resection of the right hemi-liver, most of segment four, the caudate lobe, and approximately a 10 cm section of the retrohepatic IVC, along with IVC reconstruction, was performed. Histologic examination revealed the diagnosis of a high grade leiomyosarcoma.

Infrarenal Vena Cava Leiomyosarcoma Treated With Surgical Resection and Vascular Reconstruction

Leiomyosarcoma of the inferior vena cava is a rare malignant tumor with a poor prognosis. We report a case of a 39-year-old woman admitted for a surgical resection of a retroperitoneal mass revealed by pain localised in the right lumbar fossa. Computed tomography of the abdomen revealed a heterogeneous retroperitoneal mass compressing the inferior vena cava. Surgical resection was performed with the reconstruction of the inferior vena cava using a Dacron prosthesis, the diagnosis of vessel wall leiomyosarcoma was revealed by histopathology. Surgical resection with clear margins remains the only treatment offering the best survival rate. The complex nature of the surgery of those tumors is a major therapeutic challenge for surgeons.

Modern multimodality management of patients with caval leiomyosarcoma: New treatment paradigms and potential molecular insights

BACKGROUND AND OBJECTIVES

Caval leiomyosarcomas (cLMS) are rare soft tissue sarcomas historically associated with high recurrence rates and poor prognosis. While radical resection remains the mainstay of therapy for cLMS, new systemic therapies have presented opportunities for multimodality treatment. We examined the clinical outcomes of patients with cLMS treated with modern, multimodality approaches, and compared their outcomes to those of patients with noncaval retroperitoneal LMS (ncLMS).

METHODS

A retrospective, single-institution review identified all patients diagnosed with primary retroperitoneal LMS from 2012 to 2018. Radiographic and pathologic review distinguished patients with cLMS and ncLMS. Standard clinicopathologic variables and response to chemotherapy (when applicable) were analyzed. Primary endpoints were overall (OS) and progression-free survival (PFS).

RESULTS

Eleven patients with cLMS were identified. Median tumor size was 7.5 cm (IQR, 5.0-14.3 cm); all patients had Stage II/III disease. Seven patients received neoadjuvant chemotherapy. Nine cLMS patients underwent R0/R1 resection; two did not complete resection. Six patients received adjuvant systemic therapy. Twenty patients with ncLMS were treated during the same period. No statistical intergroup differences were noted in tumor size, pathologic grade, stage, or resection margin status. Patients with ncLMS were less likely to receive neoadjuvant (10% vs. 64%) and adjuvant chemotherapy (30% vs. 55%). Two-year OS (81% vs. 78%; p = NS) and PFS (55% vs. 46%; p = NS) were comparable between cLMS and ncLMS patients.

CONCLUSIONS

Multimodality treatment with systemic therapy and aggressive surgical resection may achieve equivalent survival outcomes for patients with cLMS versus similar ncLMS. We recommend that all patients with cLMS be evaluated for multidisciplinary treatment. Genomic and proteomic expression profiling may identify novel or targetable mutations.

Retroperitoneal Castleman Disease Invading Iliac Vein and Inferior Vena Cava Treated by Tumorectomy with Vascular Repair: A Case Report

Unicentric Castleman disease, a rare lymphoproliferative disorder, is always known as a solitary, well-defined lymph node enlargement. We reported an extraordinary case of retroperitoneal Castleman disease, which invades wall of right iliac vein and inferior vena cava, treated successfully by tumorectomy with vascular repair.

Caval Reconstruction with Undersized Ringed Graft after Resection of Inferior Vena Cava Leiomyosarcoma

BACKGROUND

The en bloc resection of inferior vena cava (IVC) leiomyosarcoma often necessitates IVC reconstruction. The objective of this study is to examine outcomes after IVC reconstruction and determine optimal graft sizing.

METHODS

A retrospective review was conducted of all IVC reconstructions after IVC leiomyosarcoma resection at a single institution. Cross-sectional dimensions at the IVC resection margins were measured on preoperative imaging. The tumor location was based on the most superiorly involved region of the IVC and was classified as infrarenal, between hepatic and renal veins, or superior to the hepatic veins. Perioperative details and long-term outcomes including graft sizing, graft patency, morbidity, and mortality were recorded.

RESULTS

Between 2007 and 2017, 12 patients (6 females, mean age: 64.5 years, age range: 46-80 years) underwent IVC leiomyosarcoma resection and reconstruction. All reconstructions were performed with ringed polytetrafluoroethylene (PTFE); graft sizes ranged from 12 mm to 16 mm. The tumor location was exclusively infrarenal in seven patients, between the renal and hepatic veins in two patients, and involved multiple segments in three patients. Larger graft sizes were utilized in reconstructing more superior segments of the IVC. Grafts were typically undersized and based on the diameter of the superior resection margin with 12 mm grafts approximately correlating to a 20 mm diameter, 14 mm to 25 mm, and 16 mm to 30 mm. The average undersizing ratio was 0.6. At a mean follow-up time of 43 ± 27 months, radiographic graft patency was 92%, overall survival was 83%, and disease-free survival was 25%.

CONCLUSIONS

After en bloc resection of IVC leiomyosarcoma, caval reconstruction with an undersized ringed PTFE has acceptable patency. Grafts sizes should be based on the IVC diameter superior to the tumor and undersizing by approximately 40% appears to be associated with acceptable patency rates. Further multiinstitutional studies should be performed to best determine the optimal treatment of this rarely encountered tumor.

Inferior Vena Cava Resection and Reconstruction with Bovine Pericardium for Renal Cell Carcinoma: Complications and Outcomes

OBJECTIVES

To assess the postoperative complication rate and overall survival when bovine pericardium is used as graft material for inferior vena cava (IVC) reconstructions in patients with renal cell carcinoma (RCC). The ideal graft material is yet to be established, with synthetic grafts widely studied and used in the current literature.

METHODS

We performed a retrospective cohort analysis of consecutive patients who underwent IVC reconstructions as part of resection for RCC, using bovine pericardium as either a patch repair or tubular interposition graft.

RESULTS

A total of 15 patients underwent resection with IVC reconstruction between 2010 and 2018. Nine patients had tubular interposition grafts and 6 had patch repairs. Three patients had Clavien-Dindo grade 3 or higher short-term complications. There was no difference in Comprehensive Complications Index between those who had interposition grafts and patch repairs. Two patients had a long-term graft-associated thrombus requiring temporary anticoagulation. Overall survival was 46.5 months (95% confidence interval [CI] 36.9-56.1). There were no perioperative deaths. All long-term deaths were due to disease progression.

CONCLUSION

Reconstruction of the IVC with a bovine pericardium graft is safe in experienced centers. Bovine pericardium could be considered as the material of choice, given its safety in the immediate postoperative period, ease of use, and patency without routine long-term anticoagulation. Advanced surgical management leads to good overall survival in this cohort with high tumor burden.

En bloc removal of a large leiomyosarcoma arising from the inferior vena cava using retroperitoneal laparoscopic dissection of posterior vessels followed by cavectomy in a thoracoabdominal approach

A 55-year-old Japanese woman had a large retroperitoneal tumor involving the inferior vena cava (IVC) in the right infrahepatic space. We performed en bloc tumor resection with the right kidney and ipsilateral adrenal gland. Because of the large tumor size, we used a retroperitoneal laparoscopic approach for the posterior dissection and performed renal artery ligation. Following open conversion by a thoracoabdominal anterior approach, the tumor was completely removed without major reconstruction. Pathological examination confirmed a leiomyosarcoma arising from the IVC. Retroperitoneal laparoscopic dissection of the posterior side enabled easy and safe surgery even for a large tumor involving the IVC.

Simultaneous Surgery for Inferior Vena Cava Leiomyosarcoma with Multiple Hepatic Metastases: A Justified Challenge

Patient: Male, 42

Final Diagnosis: IVC leiomyosarcoma with multiple liver metastases

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: IVC resection with hepatectomy

Specialty: Surgery

Radiological evaluation of caudal vena cava in domestic short­hair cats with regard to right heart failure diagnosis

Radiology, an imaging technique, is used in checking small animals for cardiovascular and respiratory disorders. Cardiovascular disease such as congestive heart failure, pericardial heart disease, heart worms and disease that cause injury and lesion in the right atrium may lead to an enlarged right side of the heart and as a result cause the enlargement of caudal vena cava (CVC). It is not possible to make a complete comparison of CVC size, due to variety in size of the cats but the ratio of CVC size to the other anatomical structures makes this possibility that we have a better estimation of CVC size. So the aim of this study was to evaluate the ratio of CVC size to aorta (Ao), width of fourth rib (R4) and also the thoracic vertebral length (VL) in 20 male healthy and 20 Domestic Shorthair (DSH) cats with right heart failure (RHF). To this end, the ratio of CVC size to posterior aorta (Ao), the ratio of CVC size to width of the forth rib, the ratio of CVC size to the length of thoracic vertebrae above the site of trachea bifurcation, CVC/VL of 20 RHF cats to CVC/VL of 20 healthy SHD cats, and also Ao/VL ratios were calculated. Statistical analysis showed significant difference in the CVC/Ao and CVC/R4 between healthy and RHF cats. CVC/VL was increased in RHF cats in comparison to healthy ones (P<0.05) while Ao/VL in right heart failure DSH cats was lower than that in healthy DSH cats. The results showed that right heart failure disease in cats may lead to increase in the CVC/Ao, CVC/R4 and CVC/VL parameters in comparison with healthy cats. According to this study, the method that is used to diagnose the right heart failure in dogs could be used for cats too.

Leiomyosarcoma of the inferior vena cava: Survival rate following radical resection

Leiomyosarcoma (LMS) of inferior vena cava (IVC) is a rare neoplasm affecting approximately 1/100,000 people. The prognosis is poor and potential curative intent occurs through challenging operations, such as vena cava resection, occasionally multivisceral when required, and vascular reconstruction. There are few retrospective series regarding this retroperitoneal neoplasm, and the aim of the present study was to discuss the experience at the São Paulo Cancer Institute and Clinics Hospital of University of São Paulo Medical School, São Paulo, Brazil. The current study is a retrospective review of 7 patients treated in the two tertiary hospitals between 2005 and 2013. Oncological and operative aspects were discussed, primarily regarding surgical aspects highlighting en bloc resection, vascular reconstruction, and the overall survival and recurrence rates. All the patients were treated with radical intent, 4 of whom underwent multivisceral resection, with the kidney being the most resected organ. The location of the IVC tumor was described using Kulaylat's description and the median tumor size was 10 cm. Vascular reconstruction was necessary in 4 patients. The overall survival rate at 3 and 5 years was 100, and 25%, respectively. The disease-free survival rate at 3 and 5 years was 57 and 20%, respectively. In conclusion, IVC LMS is a rare and severe retroperitoneal neoplasm, with multivisceral resections remaining a surgical challenge. The treatment requires numerous experienced surgeons and the impact of microscopic free margins remains unclear. Vascular reconstruction depends on several aspects regarding primarily the topography of the tumor.

The enduring patency of primary inferior vena cava repair

BACKGROUND

Inferior vena cava repair after planned and unplanned venotomy is performed by either interposition bypass, patch venopasty, or lateral venorrhaphy and primary repair. Primary repair of the inferior vena cava avoids the use of foreign material and allows an all-autologous repair in an expeditious fashion. The purpose of this study was to demonstrate the utility of inferior vena cava repair, determine the degree of inferior vena cava stenosis, and examine clinical outcomes after primary repair.

METHODS

We conducted a single-center retrospective review of patients who underwent primary inferior vena cava repairs between January 2002 and January 2014 at a tertiary care center. Primary repair followed lateral venorrhaphy for tumor extraction or for repair of an iatrogenic inferior vena cava injury. Patient demographics, cross-sectional vena cava dimensions, and patient outcomes were tabulated.

RESULTS

In total, 47 (30 men and 17 women) patients underwent primary inferior vena cava repair (median age 58 years, range 31-83 years). Twenty-six patients (15 men and 11 women) underwent en bloc radical nephrectomy, inferior vena cava tumor thrombus extraction, and primary lateral venorrhaphy (median age 61 years, range 39-83 years). The majority, 92% of these patients, had renal cell carcinoma on final pathology, with a median follow-up period of 39 months (range 1-108 months). Twenty-one patients (15 men and 6 women) underwent primary repair for iatrogenic inferior vena cava injury (median age 54 years, range 31-82 years). The median follow-up period was 18.5 months (3-110 months). Clinic follow-up with postoperative imaging was obtained in 76.9% of those undergoing tumor thrombus extraction (n = 20) and 76.2% of those undergoing repair of an iatrogenic injury (n = 16). Overall, there was a 13% infrarenal inferior vena cava diameter loss, 17% inferior vena cava diameter loss at the level of the renal veins, and 10% suprarenal inferior vena cava diameter loss when comparing postoperative with preoperative imaging. All patients remained asymptomatic; therefore, inferior vena cava narrowing associated with primary repair was clinically insignificant.

CONCLUSION

Primary inferior vena cava repair is associated with less than 20% inferior vena cava diameter loss and does not compromise venous outflow from the extremities. Primary inferior vena cava repair is a safe and expeditious technique that provides excellent clinical outcomes and long-term patency.

Management of Iatrogenic Injury to the Inferior Vena Cava and Right Common Iliac Artery for Drainage of Psoas Abscess

Iatrogenic simultaneous inferior vena cava (IVC) and iliac vessel injury is a rare entity. Ligation of the IVC in a life-threatening situation is well reported in the literature. Our case demonstrates that such a clinical situation requires optimization of fluid volume and management of sequelae such as deep vein thrombosis.

Clinical Observations and Molecular Variables of Primary Vascular Leiomyosarcoma

IMPORTANCE

Vascular leiomyosarcomas are a rare subtype of leiomyosarcomas that most commonly affect the inferior vena cava and account for 5% of all leiomyosarcomas. These tumors are aggressive malignant tumors for which adjuvant modalities have not shown increased efficacy compared with surgery.

OBJECTIVES

To evaluate the outcomes of patients with vascular leiomyosarcoma and the association between vascular leiomyosarcomas and immunohistochemical molecular markers, to determine their potential prognostic and therapeutic utility.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective medical record review of a cohort of 77 patients who presented to the University of Texas MD Anderson Cancer Center in Houston during the period from January 1993 to April 2012. Data were analyzed during the period from November 2012 to May 2015. All of the patients received a confirmed diagnosis of vascular leiomyosarcoma. Immunohistochemical studies for biomarkers were performed on a tissue microarray that included 26 primary specimens of vascular leiomyosarcoma.

MAIN OUTCOMES AND MEASURES

Demographic and clinical factors were evaluated to assess clinical course, patterns of recurrence, and survival outcomes for patients with primary vascular leiomyosarcoma. A univariate Cox proportional hazards model was used to correlate disease-specific survival and time to recurrence with potential prognostic indicators.

RESULTS

Sixty-three patients with localized disease who underwent surgical resection formed the study population, and their data were used for subsequent outcomes analysis. The median age at diagnosis was 58 years (range, 22-78 years). The majority of patients were female (41 patients [65%]) and white (51 patients [81%]). The 5-year disease-specific survival rate after tumor resection was 65%. The median time to local recurrence was 43 months, the median time to distant recurrence was 25 months, and the median time to concurrent local and distant recurrences was 15 months (P = .04). Strong expressions of cytoplasmic β-catenin (hazard ratio, 5.33 [95% CI, 0.97-29.30]; P = .06) and insulinlike growth factor 1 receptor (hazard ratio, 2.74 [95% CI, 1.14-6.56]; P = .02) were associated with inferior disease-specific survival.

CONCLUSIONS AND RELEVANCE

Vascular leiomyosarcomas are aggressive malignant tumors, with high recurrence rates. Expressions of β-catenin and insulinlike growth factor 1 receptor were associated with poor disease-specific survival. Prospective studies should evaluate the clinical and therapeutic utility of these molecular markers.

Leiomyosarcoma of the Retrohepatic Vena Cava Treated by Excision and Reconstruction With an Aortic Homograft: A Case Report and Review of Literature

Leiomyosarcoma of the retrohepatic inferior vena cava is a rare entity and presents a number of diagnostic and therapeutic challenges. Here such a case is presented in which the retrohepatic inferior vena cava was excised after full mobilization of the liver under venovenous bypass. The continuity of the vena cava was restored with cryopreserved aortic homograft. The technical details with regard to total vena caval clamping, venovenous bypass, hepatic inflow occlusion, techniques of reconstruction, including the use of cryopreserved aortic homograft, and a brief review of the literature on the surgical management of retrohepatic inferior vena caval tumors are discussed.

Inferior vena cava reconstruction for leiomyosarcoma of Zone I-III requiring complete hepatectomy and bilateral nephrectomy with autotransplantation

The inferior vena cava (IVC) is the most common site of leiomyosarcomas arising from a vascular origin. Leiomyosarcomas of the IVC are categorized by anatomical location. Zone I refers to the infrarenal portion of the IVC, Zone II from the hepatic veins to the renal veins, and Zone III from the right atrium to the hepatic veins. This is a rare presentation of a Zone I-III leiomyosarcoma. Fifty-two-years-old female with a medical history significant only for HTN was admitted to the hospital with bilateral lower extremity edema and dyspnea. Two-dimensional echo demonstrated a right atrial thrombus, extending into the IVC. On subsequent CT and MRI, a 15 cm mass was noted that began in the right atrium and extended into the IVC, with continuation below the renal veins to above the level of the confluence of the common iliac veins. The patient underwent a complete resection of the mass, replacement of the IVC with Dacron graft, total hepatectomy and bilateral nephrectomy, with liver and kidney autotransplantation. Pathology was consistent with a high grade spindle cell sarcoma of vena cava origin. Patient was readmitted approximately 4 weeks postoperatively to begin adjuvant chemotherapy. This case represents a zone I-III IVC leiomyosarcoma treated with surgical R0 resection. This included a hepatectomy, bilateral nephrectomy, and hepatic and left renal autotransplantation. These complex tumors should be treated with surgical resection, and require a multidisciplinary approach.

Older soft tissue sarcoma patients experience increased rates of venous thromboembolic events: a retrospective cohort study of SEER-Medicare data

BACKGROUND

Venous thromboembolic co-morbidities can have a significant impact on treatment response, treatment options, quality of life, and ultimately, survival from cancer. There is a dearth of published information on venous thromboembolic co-morbidity among older soft tissue sarcoma patients.

METHODS

SEER-Medicare linked data (1993-2005) was utilized for this retrospective cohort analysis (n = 3,480 soft tissue sarcoma patients). Non-cancer patients were frequency-matched by age to cancer patients at a ratio of 1:1; coverage and follow-up requirements were the same as for soft tissue sarcoma cases. Venous thromboembolic events were divided into three groups of interest: deep vein thrombosis, pulmonary embolism, and other thromboembolic events. Relative incidence rates of venous thromboembolic events in soft tissue sarcoma patients with a recent history of cardiovascular event or venous thromboembolic event (12 months before diagnosis) versus soft tissue sarcoma patients without such a recent history were calculated using the Cox proportional hazard models. The Cox proportional hazard model was used to build predictive models to identify important risk factors for each venous thromboembolic event of interest among soft tissue sarcoma patients. Relative incidence rate of VTEs in cancer patients (12 months after diagnosis) versus non-cancer cases (12 months after index date) was calculated using multivariable Cox proportional hazard models.

RESULTS

We observed that among older soft tissue sarcoma patients, 10.6% experienced a deep vein thrombosis, 3.0% experienced a pulmonary embolism, and 3.1% experienced other thromboembolic events in the 12 months after sarcoma diagnosis. On average, 60% of venous thromboembolic events occurred in the first 90 days after sarcoma diagnosis. The highest rates of deep vein thrombosis and pulmonary embolism after sarcoma diagnosis were seen in patients with sarcoma not otherwise specified (deep vein thrombosis: 204/1,000 p-y and pulmonary embolism: 50/1,000 p-y). Recent history of a venous thromboembolic event was the strongest predictor of a subsequent venous thromboembolic event after soft tissue sarcoma diagnosis.

CONCLUSION

Venous thromboembolic events are common and serious co-morbidities that should be closely monitored in older soft tissue sarcoma patients.

Duodenocaval Fistula in a Patient with Inferior Vena Cava Leiomyosarcoma Treated by Surgical Resection and Caval Polytetrafluoroethylene Prosthesis

Inferior vena cava (IVC) leiomyosarcoma represents an extremely rare disease that commonly involves the segment between the inflow of the renal veins and the inflow of the hepatic veins (46% of cases). We report the case of a patient affected by an IVC leiomyosarcoma, treated with surgical resection, caval reconstruction with polytetrafluoroethylene (PTFE), and right nephrectomy, followed by external beam radiotherapy. Oncological follow-up was negative for 17 years after this combined treatment, since the patient developed a duodenocaval fistula (DCF).

Leiomyosarcoma of the inferior vena cava: a case report

The authors report a case of a 48 year-old female patient with moderate abdominal pain and bulging in the abdomen. Physical examination demonstrated the presence of a palpable abdominal mass. Computed tomography showed a heterogeneously enhancing retroperitoneal mass in close contact with the inferior vena cava. En bloc resection of the mass and of the attached vena cava segment was performed. Histological analysis revealed leiomyosarcoma.

Management of extensive retrohepatic vena cava defect in recipients of living donor liver transplantation

Certain complexities, such as extensive vena caval injury, unexpected dense adhesions between liver and retrohepatic vena cava, and liver tumor abutting retrohepatic vena cava, sometimes warrant resection of vena cava during living-donor liver transplantation. Because the donor graft is devoid of vena cava, reconstruction of the retrohepatic cava is required, which can be done with the use of either a cryopreserved venous graft or an artificial conduit. With only a few published reports, the experience in vena cava reconstruction with the use of expanded polytetrafluoroethylene (ePTFE) during living-donor liver transplantation remains limited. We present our experience of 4 patients who successfully underwent vena caval resection during liver transplantation for various indications, which was subsequently reconstructed with the use of ePTFE grafts. All of these patients except 1 recovered well without any undue complications, such as thrombosis or outflow inadequacies, thus proving this extensive surgical treatment to be a successful and life-saving procedure, though meticulous skills are prerequisite.

Challenging diagnostic and therapeutic modalities for leiomyosarcoma of inferior vena cava

Leiomyosarcoma of the inferior vena cava (IVCL) is a rare malignant tumour originating from the smooth muscle cells of the media with intra- or extra-luminal growth. The type of the lesion is further divided into three levels in relation to hepatic and renal veins respectively. The aim of this review was to evaluate the results of surgical treatment of IVCL with special reference to the extent of its histological spread and to analyse the recent literature in order to provide an update on the current concepts of diagnostic and therapeutic management of this entity. IVCL's patients may present with non-specific complaints such as dyspnoea, malaise, weight loss, nausea, vomiting, fever and abdominal pain. Haematogenous metastasis is frequent. At a later stage, IVCL may also spread through lymphatic. Multiple diagnostic imaging techniques have been proposed for accurate preoperative diagnosis, including Doppler ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI), individually or in combination with cavography echocardiography or CT-guided biopsy. Despite recent research on the therapeutic strategies against IVCL, surgical resection appears the only potentially curative approach. Unfortunately, a mere minority of patients is eligible to undergo surgical intervention. In addition, surgical removal of IVCL does not necessarily guarantee patient's long-term survival. Alternative therapies, such as radio- and chemo-therapy often proved insufficient. Debate continues regarding the optimal management of the IVC after tumour resection, with primary repair, ligation and IVC reconstruction all have been utilized with varying success.

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.

Surgical management of retroperitoneal leiomyosarcoma arising from the inferior vena cava

Retroperitoneal leiomyosarcomas are uncommon tumors, with approximately 300 documented cases in the literature. Management necessitates complete surgical resection in order to offer patients a chance at long-term cure. Resection often presents a challenge as these tumors are often large, involving adjacent structures, and may require reconstruction of the inferior vena cava (IVC). In this article, we will present background information on retroperitoneal leiomyosarcomas and the technical aspects of surgical resection and vascular reconstructive options of the IVC.

Leiomyosarcoma of the inferior vena cava level II involvement: curative resection and reconstruction of renal veins

Leiomyosarcoma of the inferior vena cava (IVCL) is a rare retroperitoneal tumor. We report two cases of level II (middle level, renal veins to hepatic veins) IVCL, who underwent en bloc resection with reconstruction of bilateral or left renal venous return using prosthetic grafts. In our cases, IVCL is documented to be occluded preoperatively, therefore, radical resection of tumor and/or right kidney was performed and the distal end of inferior vena cava was resected and without caval reconstruction. None of the patients developed edema or acute renal failure postoperatively. After surgical resection, adjuvant radiation therapy was administrated. The patients have been free of recurrence 2 years and 3 months, 9 months after surgery, respectively, indicating the complete surgical resection and radiotherapy contribute to the better survival. The reconstruction of inferior vena cava was not considered mandatory in level II IVCL, if the retroperitoneal venous collateral pathways have been established. In addition to the curative resection of IVCL, the renal vascular reconstruction minimized the risks of procedure-related acute renal failure, and was more physiologically preferable. This concept was reflected in the treatment of the two patients reported on.

Leiomyosarcoma of the inferior vena cava in a patient with double inferior vena cava

BACKGROUND

Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor arising from its smooth muscle cells.

METHODS AND RESULTS

We report the case of a 38-year-old woman presenting with back pain and weight loss who was diagnosed with a 22-cm leiomyosarcoma of the right IVC and thrombosis of the left IVC. The patient is alive and free of recurrence a year after radical tumor resection with removal of the affected IVC, reconstruction with polytetrafluoroethylene prosthetic graft, and anastomosis of both right and left IVC.

CONCLUSIONS

Leiomyosarcoma is a rare and aggressive tumor with a deceitful course. Radical surgical en bloc resection is the mainstay of treatment for IVC leiomyosarcomas. For an adequate restoration of venous return, complex vascular repair may be necessary.

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.

Inferior vena cava resection and reconstruction for retroperitoneal tumor excision

OBJECTIVE

This study reviews the results of en bloc resection of the inferior vena cava (IVC) for malignant tumor excision and reconstruction.

METHODS

A prospective database was reviewed. IVC resection was categorized as suprarenal, perirenal, infrarenal, or extensive (>one segment resected). Repairs were divided into primary, patch, or circumferential. Tumor type, perioperative morbidity, mortality, and graft patency were recorded.

RESULTS

Between 1990 and 2011, 47 patients (21 women; mean age, 56; range, 35-89 years) underwent IVC resection for en bloc tumor excision. Sarcomas were most common (36 [77%]: 30 primary IVC). Eleven patients had primary IVC repair, nine patch repair (two autogenous), and 27 had circumferential replacement with a polytetrafluoroethylene ringed graft. Extensive IVC reconstruction in 18 patients included the entire IVC, with renal (RV) and hepatic vein reimplantation in eight; suprarenal and perirenal in six (seven RVs reimplanted); and infrarenal and perirenal in four (four RVs reimplanted). Nine single-segment IVC replacements were infrarenal. Morbidity was 10.6%: one each with bowel obstruction, chyle leak, renal failure with complete recovery (left RV reimplant, right nephrectomy), reoperation for bleeding, and IVC graft thrombosis. Morbidity did not differ by type of reconstruction. There was no mortality. Follow-up ranged from 1.5 to 216 months (18 years) with a mean of 3.5 years. Computed tomography or duplex scans were available in 28 of 47 patients and in 15 of 27 patients in group 3 at a mean follow-up of 36 and 20 months, respectively. One IVC graft thrombosis was documented at 10 months after chemotherapy/sepsis. Tumor recurrence caused three graft stenoses. Cumulative 5-year patency in group 3 was 80% (imaging) and 92% (clinical). Lower extremity edema was universally avoided. Cumulative 5-year survival for the series was 45% ± 8.5%. Mean long-term survival was 5.8 ± 0.56 years (range, 4 months-17 years), with a significant difference between primary or patch (mean, 6.5 years) and circumferential or extensive repair (mean, 4.2 years; P < .005). Cumulative (47% vs 52%) and mean (3.1 vs 3.6 years; P > .12) survival was similar between patients with single-segment and extensive IVC resection and replacement.

CONCLUSIONS

IVC resection and reconstruction for en bloc tumor excision is safe, even when extensive repairs are necessary. Replacement of the IVC with prosthetic graft avoids extremity venous complications and likely contributes to quality of survival. Survival depends on tumor behavior and degree of IVC involvement, where primary and patch repair has a better prognosis than circumferential resection.

Classification, molecular characterization, and the significance of pten alteration in leiomyosarcoma

Leiomyosarcoma is a malignant smooth muscle neoplasm with a complicated histopathologic classification scheme and marked differences in clinical behavior depending on the anatomic site of origin. Overlapping morphologic features of benign and borderline malignant smooth muscle neoplasms further complicate the diagnostic process. Likewise, deciphering the complex and heterogeneous patterns of genetic changes which occur in this cancer has been challenging. Preliminary studies suggest that reproducible molecular classification may be possible in the near future and new prognostic markers are emerging. Robust recapitulation of leiomyosarcoma in mice with conditional deletion of Pten in smooth muscle and the simultaneous discovery of a novel role for Pten in genomic stability provide a fresh perspective on the mechanism of leiomyosarcomagenesis and promise for therapeutic intervention.

Multidisciplinary treatment and long-term outcomes in six patients with leiomyosarcoma of the inferior vena cava

Purpose

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare primary soft tissue sarcoma. Few reports have detailed the tumor features, treatment strategies, and long-term outcomes in IVC LMS patients. The present report describes the treatment and long-term outcomes of six patients with IVC LMS.

Methods

We reviewed six consecutive cases of IVC LMS treated at the University of Ulsan College of Medicine, Asan Medical Center from August 1998 to June 2010.

Results

The patients comprised five females and one male, and had a median age of 44 years (range, 25 to 64 years). All tumors were suprarenal. The tumors were located between the hepatic and renal veins (i.e., middle segment; n = 5 [83%]), or above the hepatic veins (i.e., upper segment; n = 1 [17%]). Prosthetic IVC replacement using polytetrafluoroethylene grafts was performed in five patients, and the remaining patient underwent only tumor resection and IVC ligation. There were no intraoperative or postoperative deaths. The mean tumor size was 9.3 cm (range, 5 to 20 cm), and five of the six tumors were high grade. The mean follow-up period was 80 months (range, 6 to 118 months). The median survival period was 94 months. Recurrence occurred in all patients. Distant recurrence resulted in three patients undergoing lung resection and three patients undergoing thigh muscle resection.

Conclusion

IVC LMS is a rare but serious disease. Although surgical resection combined with chemoradiotherapy was not completely curative, it resulted in long-term patient survival, even in patients with advanced tumors.